WORKERS COMPENSATION LIABILITY FORM.PDF

INDUSTRIAL COMMISSION OF ARIZONA
WORKERS' COMPENSATION LIABILITY FORM
1. NAME OF SELF-INSURER: MARICOPA COUNTY
2. EMPLOYEE COUNT 1 3,969 Total Employee Count from prior anniversary date to current
(W-2 count to include all full & part time employees that worked regardless of whether or not they are
still employed). Explain decrease from prior year on separate cover.
3. SECURITY DEPOSIT CALCULATION
(Number of Claims, Incurred Liability and Paid amounts must be calculated from the
Effective Date of Self-Insurance Authority to the present date):
A
Total Incurred Paid Total Incurred Paid Total TOTAL
Amount Medical Medical Medical Comp. Comp. Comp. ALL
of Owed Owed CLAIMS
Open (B — C = D) (E — F = G) (D + G = H)
Claims
279 20,949,58 14,903,357 6,046,223 17,600,44 7,244,964 10,355,483 16,401,706
0 7
Total Owed from Column H: $ 16,401,706
Excess insurance reimbursement amount expected: $ 5,580,849
Net remaining liability: $ 10,820,857
Multiply by 125%: $ 13,526,071
Calculated Security Deposit: (minimum security deposit $100,000.00) $ 13,526,071
4. Name of Excess Insurance Carriers providing reimbursement: (provide detailed report with carrier
name, SIR amount, claimant names, DOT and claim number, reimbursement amount requested)
(List the Policy Yea r(s) of Reimbursement taken) See attached Loss and Excess Credit Worksheet
Shelby L. Scharbach attest that there is no affiliate relationship between the self-
insurer and the excess insurance carrier and to the truthfulness of the above information.
Self-Insurers Authorized Representative Signature:
Printed Name/Title: Shelby L. Scharbach, Asst County Manager - CFO
DATE: /// 4' * Must be signed by Designated Officer
Workers' Comp Liability Form - Revised 11/8/2011