Worker's Compensation Self-Insurance Worksheet

This worksheet can be used to:

Self-Insurance Worksheet 1st Year 2nd Year 3rd Year
A. If operating as an insured employer under the Act:      
  1.  Net amount payable in WC premiums      
  2.  Amount of other WC payments and costs payable, e.g., safety violations and certain other penalties, WC related administrative costs, et cetera      
  3.  Total amount payable as an insured employer, A(1) + A(2), above and compare with B(6) below      
B. If operating as a self-insured employer under the Act:      
  1.  Medical, indemnity and other WC benefits payable by employer      
 

a.  Medical, indemnity and other WC benefits payable by employer

      
 

b.  Other amounts payable by the insurance company under the excess policy/policies

      
 

c.  Present value of additional amounts payable by insurance company at end of year under excess policy/policies

      
 

d.  Present value of additional amounts payable by employer at end of year

      
  2.  Other amounts payable under the WC act., e.g., assessments, safety violations and other penalties, et cetera      
  3.  WC premiums payable for excess coverage and surety bond (bond required by Department)      
  4.  Other WC payments and costs payable, i.e., claims service organization, employer's administrative costs for safety and health, claims handling, et cetera      
  5.  Total Amounts payable during year - B(1)a + B(2) + B(3) + B(4), above =      
  6.  Total amounts payable and present value of amounts payable at end of year by employer = B(1)d + B(5), above =      
C. Extrapolate A(3) and B(6) for another seven years, and compare them; note the divergence