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The total unpaid liability on all open claims on which compensation 2026
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- Click ‘Get Form’ to open it in the editor.
- Enter the name of the self-insured employer, year, and select the semi-annual date at the top of the form.
- In Column 1, input the total number of open claims as of the reporting date.
- For Column 2, report the total incurred medical only liabilities, including both paid and anticipated unpaid amounts.
- In Column 3, enter the total dollar amount paid on medical only claims reported in Column 2.
- Calculate and enter the unpaid medical only amount in Column 4 (Column 2 minus Column 3).
- Repeat similar steps for Columns 5 through 8 for indemnity claims and total unpaid liability calculations.
- Complete any additional sections regarding excess insurance carrier reimbursement if applicable.
- Finally, ensure that a corporate officer signs and certifies the form before submission.
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