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Click ‘Get Form’ to open the INSTRUCTIONS FOR FORM IC-211 in our editor.
Begin by entering the name of the self-insured employer, the year, and selecting 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. Ensure accuracy for compliance.
Proceed to Column 2 and enter the total incurred liability for all Medical Only claims, including anticipated unpaid liabilities.
In Column 3, record the total dollar amount paid on Medical Only claims reported in Column 2.
Calculate and enter the unpaid medical amount in Column 4 (Column 2 minus Column 3).
Continue filling out Columns 5 through 8 similarly, ensuring all calculations are accurate and rounded to the nearest dollar.
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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