Department of Labor and Industry

Canceled Carrier Information

Cancelled Carrier

Cancelled Carrier

WORKERS' COMPENSATION FINANCIAL / LOSS UPDATE FOR ALL PRIOR SELF-INSURED CARRIERS (PLAN 1)

Employers and Employer groups that previously self-insured their workers' compensation liabilities in Montana (Plan 1) 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 requires periodic updates on the employer’s workers' compensation and occupational disease claims for the self-insured period. 

The Department’s self-insurance financial / loss update form is the required format for this update and is available below in Adobe PDF under the Cancelled Carrier Update tab. A Microsoft Excel version of the form is also available by contacting us using the contact information listed below.

All prior Plan 1 carriers are required to submit the completed self-insurance financial / loss update form by January 31st each year along with a copy of the most recent annual report or audited financial statement.  You may also send your update electronically to the contact information listed below.

Form

Cancelled Carrier Update (excel)
Cancelled Carrier Update (pdf)

Contact Information

Workers' Compensation Regulations Bureau
Program Manager for Self-Insurance

Erin Weisgerber
(406) 444-1555
EWeisgerber@mt.gov