12-31-2015 AMENDMENT TO INCREASE.PDF

Charles "Hos" Hoskins, Treasurer
301 West Jefferson St., Rm, 100
Phoenix, Arizona 85003
Phone: (602) 506-8511
Maricop a County Fax: (602) 506-1102
hftp://treasurer.marieopa.gov
Treasurer
November 17, 2015
JPMorgan Chase Bank
Chris 201 N. Peterson Central Ave., 21s t fl, AZ1-1179
Phoenix, AZ 85004
Re: L/C No CTCS-920941
Dear Ms. Peterson:
Compensation Liability Form calculates the County's
Maricopa County's Workers' Industrial Commission of Arizona (ICA) to be
required security deposit with the Credit is $15,151,706 and we are requesting it be
$15,705,634. The current Letter of which is the amount required by the ICA.
increased by $553,928 to $15,705,634
Sincerely,
afres""rlos" HoVtifis
County Treasurer

INDUSTRIAL COMMISSION OF ARIZONA
WORKERS' COMPENSATION LIABILITY FORM
1. NAME OF SELF-INSURER: Maricopa County
2. EMPLOYEE COUNT 13,888 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
280 21,119,141 14,797,914 6,321,227 18,371,463 6,919,037 11,452,425 17,773,652
Total Owed from Column H: $17 773 652
Excess insurance reimbursement amount expected: $ 5,209,145
Net remaining liability: $12 564 507
Multiply by 125%: $15 705 634
Calculated Security Deposit: (minimum security deposit $100,000.00) $ 15,705,634
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 Year(s) of Reimbursement taken) See Attached Loss and Excess Credit Worksheet
I, 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. Seharbach, Asst County Manager - CFO
DATE: * Must be signed by Designated Officer
Workers' Comp Liability Form - Revised 11/8/2011