Canceled Carrier Update (MS Word)
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Cancelled Carrier
WORKERS' COMPENSATION
FINANCIAL / LOSS UPDATE
For
CANCELED SELF-INSURANCE EMPLOYERS
Introduction: This section is intended for employers who were previously self-insuring their workers' compensation liabilities in Montana (Plan 1). All self-insured employers remain subject to Montana Department of Labor jurisdiction as long as there are any open or re-opened claims, any outstanding liabilities for the self-insured period, or any disputes existing concerning payment of any self-insured claim. The Department, from time to time, requires periodic updates on the company's workers' compensation and occupational disease claims for the period the company was self-insured.
New since 2001: the self-insurance financial / loss update form is available in either (1) Microsoft Excel format or (2) Microsoft Word format. These two versions can be found on the Internet at the links in the left menu:
(1) The Microsoft Excel Version. Please fill in the necessary information in the colored cells of the Microsoft Excel form. The totals on page 2 of the form are calculated automatically. Dates should be entered as mm/dd/yyyy (month, day, year). You may send the financial / loss update form via email to speed up the process, but we will still need a hard copy of the form that includes your signatures.
(2) The Microsoft Word financial / loss update form version has been designed for you to print out on your local printer, so you can then fill in the appropriate information by typewriter or pen.
Please provide two (2) copies of your most recent annual report or audited financial statements along with your financial / loss update form.
These changes and improvements are intended to provide better customer service for you. We welcome your comments and suggestions.
Jeff Lapham
Program Manager for Self-Insurance
jlapham@mt.gov
