The total unpaid liability on all open claims on which compensation 2026

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

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