NC SIWC Annual Filing – Attestation and Annual Filing Instructions

Fiscal Year Ended:

Note: Annual filings are due to the North Carolina Department of Insurance (“Department”) AND to the North Carolina Self-Insured Security Association (“NCSISA”). Please contact the NCSISA concerning their annual filing requirements.

Company Information Company Name

Company Mailing Address Street City State Zip

Company Phone Contact Name Contact Title

Contact Mailing Address Street City State Zip

Contact E-mail Address Toll Free (if available) Contact Phone Number

Include extension in the box below (if applicable).

Extension

Annual Reporting Requirements (G.S. § 97-180(a) through (c))

North Carolina General Statute (“G.S.”) §97-180(a) through (c) details the annual reporting information required to maintain your Self-Insured Workers’ Compensation license. This information is due to the North Carolina Department of Insurance (“Department”) no later than 120 days following the end of your fiscal year:

Certified Audited Financial Statement (G.S. § 97-180(a)): Every self-insurer shall submit a certified audited financial statement, prepared by a CPA or submitted by a foreign registered public accounting firm, for the previous fiscal year-end. The financial statement presentation shall facilitate the application of ratio and trend analysis. If the self-insurer was issued a license pursuant to GS §97-177, the financial statement required under GS §97-180(a) shall be that of the guarantor.
Actuarial Certification (G.S. § 97-180(b)): Every self-insurer shall submit a report from a qualified actuary setting forth an opinion certifying the loss and loss adjustment expense reserves for workers' compensation obligations in North Carolina. The report shall show liabilities, excess insurance carrier and other qualifying credits, if any, and net retained workers' compensation liabilities. The actuary report must include an estimate of ALAE, ULAE and IBNR expenses.
Statement of Workers’ Compensation Benefits and Obligations (G.S. § 97-180(c)): Every self-insurer shall submit a report in the form of a sworn statement prescribed by the Commissioner, setting forth the total workers' compensation benefits paid in the previous fiscal year, and the total outstanding workers' compensation liabilities for each loss year, recorded at the close of its fiscal year for the net retained liability. This form is available on the Department’s website by accessing the following hyper-link: https://files.nc.gov/doi/documents/self-insured-workers-compensation/benefitsactive.pdf

Other Requested Information

In addition to the above, please provide, in accordance with N.C. Gen. Stat. § 97-190(c), a current excess insurance policy and amendments, if any, from a licensed North Carolina insurance company, a captive insurance company licensed in North Carolina, or an eligible surplus lines insurer as defined in N.C. Gen. Stat. § 58-21-10, that verifies the specific and aggregate excess insurance amounts. The excess insurance policy MUST indicate Specific Limit, Specific Retention, Aggregate Limit and Aggregate Retention amounts. Please indicate these amounts below. If the Commissioner has approved a waiver of aggregate excess loss coverage, please provide evidence of the waiver.

Specific Limit ($) Specific Retention ($) Aggregate Limit ($) Aggregate Retention ($)

Questions

If you have any questions regarding the annual filing requirements, or if you anticipate a problem meeting the filing deadline, please contact one of the Special Entities Section staff at the following contact numbers:

Mike McKinney — (919) 807-6628 — Mike.McKinney@ncdoi.gov

Attestation

I attest that (the Company) has provided the required annual filing information as set forth above as of .

Signature of Corporate Officer Title of Corporate Officer