Terminated Individual Employers Self-Insured for Workers’ Compensation – Statement of Workers’ Compensation Benefits and Obligations

The North Carolina General Statutes §97-180 (c) requires that every self-insurer submit within 120 days after the end of its fiscal year 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, as well as 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 to be completed by self-insurers with terminated license status but have remaining outstanding losses incurred during the period licensure.

Complete and return this form to the North Carolina Department of Insurance, Financial Analysis & Receivership Division, Special Entities Section, 1203 Mail Service Center, Raleigh, NC 27699-1203.

Certification This is to certify that the (Corporation) (Corporate Address)

• Has total outstanding North Carolina workers’ compensation liabilities recorded in the financial statements of $ at fiscal year-end .

(This amount represents total future North Carolina workers’ compensation obligations for each and every loss year for both case and incurred but not reported (IBNR).)

Has the above stated company provided all information required by the actuary in a true and accurate form that will assist the actuary in expressing an opinion in the Actuarial Certification filed with this Department?

Yes No

If no, please explain.

Corporate Officer Certification Title of Corporate Officer Signature of Corporate Officer Please Print Name of Corporate Officer