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.