Form WC-83: Statement of Outstanding Losses, as of December 31 of the reporting year. Estimated future payments for all losses (indemnity, medical, and expense) for the self-insured period must be given. The grand total of all expected future payments must be shown on the first page. If the grand total is not listed, the report will be returned as incomplete. All cases and related payments including those made under Section 287.957 RSMo are to be included. If you submit a detailed loss run of all open and closed cases for each year of self-insurance authority, you need only to insert the grand total of estimated future payments from the loss run on page 1 of the WC-83 form. The WC-83 form must still be signed and notarized. Cases with lifetime medical benefits must be noted.
*Please note that the highlighted areas on the forms are areas that MUST be completed.
Instructions:
- Include all open cases including all med only
- Include PTD or Death claims only if applicable
- If submitting a detailed loss run, first line must read: See attached loss run
- Total outstanding liability for each respecting injury that has an outstanding liability (total incurred minus total paid)
- Form must include the name of the self-insured entity
- Total must be filled in, even if attaching documents or the total is zero.
