HomeMy WebLinkAbout10 WORKERS COMP RPT 09-16-02AGENDA REPORT
09-16-02
MEETING DATE: SEPTEMBER 16, 2002 180-60
TO:
WILLIAM A. HUSTON, CITY MANAGER
FROM:
HUMAN RESOURCES DEPARTMENT
SUBJECT:
WORKERS' COMPENSATION SELF INSURERS ANNUAL REPORT
RECOMMENDATION: RECEIVE AND FILE
FISCAL IMPACT: NONE
BACKGROUND AND DISCUSSION:
Each year the City is required to file an annual report with the State of California
Department of Industrial Relations Self Insurance Plans Division because we are self
insured for purposes of Workers' Compensation. The report provides information on the
number of claims opened and closed, the incurred liability, amounts paid to date and
anticipated future liability. The report also provides information on the City's third party
administrator (in fiscal year 01/02 this was Hazelrigg Risk Management Services, Inc),
records storage, excess insurance coverage, and the methodology for funding of our
program.
Pursuant to Labor Code Section 3702.6 (b) each public self insurer is required to advise its
governing board within 90 days after submission of the Self Insurers Annual Report of the
total liabilities reported and that the current funding of such liabilities is in compliance with
the requirements of Government Accounting Standards Board (GASB) Publication 10.
In compliance with this requirement, attached is a copy of the annual report (absent
confidential individual claim detail) filed with the State on September 9, 2002. Further, as
required, the funding of the liabilities is in compliance with GASB requirements.
Arlene Marks, SPHR
Director of Human Resources
Attachment: Public Self Insurer's Annual Report for Non-JPA Member Fiscal Year
Ending June 30, 2002
S:\City Council Agenda Items\Staff Report Workers' Compensation self ins.doc
Completes this page on ALL reports
STATE OF CALIFORNIA
DEPARTMENT OF INDUSTRIAL RELATIONS
SELF INSURANCE PLANS
2265 Watt Avenue, Suite 1
Sacramento, CA 95825
Web site http: //sip. d_ir. ca. gov
E-mail: sip~dir, ca. gov
1.
PAGE 1
YEAR ENDING ,June 30, 2002
PUBLIC SELF INSURER'S ANNUAL REPORT
0Non-JPA Member)
CERTIFICATE NUMBER: 4-7171-01-164 2. PERIOD OF REPORT: ~ Full Year
I Iinterim Report For The Period of:
Status Active 07 /0//0[ to O~ /~) /O~
Mo Day Yr Mo Day Yr
3. NAME OF MASTER CERTIFICATE. HOLDER:
4.
City of Tustin
300 Centennial Way
ADDRESS OF MAIN HEADQUARTERS
Tustin CA 92680
CITY, STATE ZIP+A
TYPE OF PUBLIC AGENCY: CITY
~ CITY/COUNTY ~ HOSPITAL
~ SCHOOL ~ TRANSIT
Federal Tax Identification
No: 95-6000804
DURING THE PERIOD OF THIS REPORT, HAS THERE BEEN ANY' OF THE FOLLOWING WITH RESPECT
TO THE MASTER CERTIFICATE HOLDER, SUBSIDIARY OR AFFILIATE CERTIFICATE HOLDER?
(IF YES, EXPLAIN ON REVERSE SIDE OF THIS PAGE.)
6.
A MERGER OR UNIFICATION?
..
CHANGE IN NAME OR IDENTITY?
ANY ADDITION TO SELF INSURANCE PROGRAM?
Yes ~ No
~Yes ~ No
ARE THERE AlxUf AGENCY EMPLOYEES NOT INCLUDED iN YOUR WORKERS' COMPENSATION
SELF INSURANCE PROGRAM?
Yes F~ No
IF YES, WHAT EMPLOYEES' ARE NOT INCLUDED?
7.
CovERED
r--i
ARE THESE EMPLOYEES BY AN INSURANCE POLICY? L_~Yes--I[N°
~ THESE EMPLOYEES COVERED BY ANOTHER SELF INSURANCE CERT. OR JPA?~Yes ~No
TO WHOM DO YOU WANT CORRESPONDENCE ADDRESSED?
NAME Arlene Marks
TITLE Director of Human Resources
COMPANY NAME City of Tustin
ADDRESS 300 Centennial Way
Tustin, CA 92680
TELEPHONE (714)573-3040 FASCIMILE (FAX) NUMBER (714)832-6382
CERTIFICATION BY AGENCY OFFICIAL:
I declare under the penalty of perjury that I have examined this
Self Insurer's An. nual'Report and to the best of my knowledge and
belief it is true, corre.,, ~t and complete.
Signature: ~vva-'~n~nal ~ignature Only Date: 9/9/02
Typed Name: Amiens Ma~ks
Agency Name: C~t~ Of Tust~n
~,'~'~: 300 Centennial Way
Strg~? A~d~e~
City: Tustin StateC:A~ ziP+4:92780-3715
Telephone: (714)_573 _ 3052 Fax: (714)832 _ 6382
Fiscal Year
01/02
Annual Report is Due October 1, 2002
Form A4-40b (4/92)
NOJ'E: Claims Administrator
Complete this page for ALL reports except item B
Employment/Wages, which is completed by
Self insured employer.
Page 2
Fiscal Year Ending June 30, 2002
Certificate Number:
II. CONSOLIDATED LIABILITIES
Name of Master Certificate Holder: City of Tustin
Type of Report:
[] Original Report (Due October 1 each year)
[] Interim/Amended Report for the Period of:
Io1.,Io1 1o1 / I01 131olol2 1
Month Day Year to Month Day Year
A. CASES AND BENEFITS (to nearest dollar) [
Incurred Liability Paid to Date Future Liability
Number $Indemnity $ Medical $ Indemnity $ Medical $ Indemnity $ Medical
1. Cases open
as of 6/30/2002
10 256,283 515,977 251,666 396,305 4,617 I 19,672
reported prior
to FY 1997-98
2. Open& Closed Cases:
a- FY 1997-98 llll~
Total cases 43 260,299 115,893 260,299 110,893
reported 0 5,000
I FY1997'98b. FYCases1998-99open 1 75,962 74,888 75,962 69,888 il
Total eases 51 ~ 155,457 163,354 139,642 156,349
reported 15,815 7,005
I FY 1998-99 c. FY Cases 1999-2000 open 2 46,347 59,519 30,532 52,514 lll~
Total cases 38 108,776 86,390 103,471 49,727
reported 5,305 36,663
I FY 1999-2000d. FyCaSes2000-20ol°pen 5 20,305 63,340 15,000 26,677 llll
Total cases 31 117,340 77,475 81,963 57,626
reported 35,377 19,849
I FY2000'2001e. FyCaSes2001open-2002 6 117,340 65,722 81,963 '45,873 1i
Total eases 46 189,304 136,082 60,027 62,140
reported 129,277 73,942
I FY 2001-2002
25 189,304. 121,606 60,027 47,664 ~ /l
Cases
operl
$ Indemnity $ Mediea~
SUBTOTAL 190,391 262,131
3. ESTIMATED FUTURE LIABILITY (Indemnity plus Medical) TOTAL 452,522
$ Indemnity I $ Medical
4. Total Benefits paid during FY 2001-2002 (include all case expenditures): ........................ 133,391[ 148,081
5. Number of Medical-ONLY cases reported in FY 2001-2002: ....................................
6. Number of INDEMNITY cases report in FY 2001-2002: .......................................
7. TOTAL of 5 and 6 (also enter in 2e above): ..................................................
8. TOTAL number of open indemnity cases (all years):, ..........................................
9. Number of Fatality cases reported in FY 2001-2002: ..........................................
32
14
46
33
0
3
0
10. (a) Number of FY 2001-2002 claims for which the employer or administrator was
notified of representation by an attorney or legal representative in FY 2001-2002: ..............
(b) Number of non-FY 2001-2002 claims for which the employer or administrator was
notified of representation by an attorney or legal representative in FY 2001-2002: ..............
B.
TOTAL EMPLOYMENT AND WAGES PAID IN FISCAL YEAR 2001-2002
FOR THIS SELF INSURER:
(a) NUMBER OF EMPLOYEES 333
(Number of individual employees listed on Form DE-6 for year ending June 30, 2002)
Co) TOTAL WAGES AND SALARIES PAID $ 16,498,227
(As reported on EDD Form DE-6 Line M for all four quarters)
Fiscal Year
01/02
Page 2 (Rever~ Side)
HA. ADMINISTRATOR
A. NAME OF CURRENT ADMINISTRATOR(S)/ADMINISTRATING AGENCY(IES) AT THE TIME OF PREPARING THIS REPORT.
1. Name (Person) Alan Schiller Administrative Agency's
Agency Name Hazelrigg Risk Management Services, Inc. Certificate No.: 11 I 6 I 4 I
Address 14275 Pipeline Avenue or ["-] Self Administrated
city Chino state CA zip+4 91710
2. Name (Person)
Agency Name
Address
City
3. Name (person)
State Zip+4.
Agency Name
Address
Administrative Agency's
Certificate No.: I I I]
or l-"l self Administrated
Administrative Agency's
Certificate No.: 1'1 I I
or I'~ Self Administrated
City
4. Name (Person)
State Zip+4
Agency Name
Address
City State Zip+4
Administrative Agency's
Certificate No.: I lll
or I~ Self Administrated
B. HAS THERE BEEN A CHANGE IN ADMINISTRATOR/ADMINIST~~ AGENCY DURING THIS
REPORT PERIOD? [] YES [] NO IF YES, DATE OF CHANGE: I I ]
[ I I ]
Month Day Year
TYPE OF CHANGE: {--] Change in Administrative Agency
[] Change to or from Self Administration
C. NAME OF PRIOR ADMINISTRATOR(S)/ADMINISTRATIVE AGENCY(IES):
Name
Agency Name
Address
City State .~ Zip+4
CERTIFICATION
I declare under penalty of perjury that I have prepared or caused this report to be prepared and I have examined this
consolidated report of this self-insurer's workers' compensation liability. To the best of my knowledge and belief this report is
true, correct and complete with respect to the workers' compensation liability incurred and paid. I further declare under the
penalty of perjury that the estimates of future liability of workers' compensation claims mad~ in this report reflect the
administrator's best judgment as to the future liability of claims, using prevailing industry standards, and the signatory
inten_ds Self Insu~ngg P~s to rely upon the representation. ~_. .
Original Signature of Administrator (Person) Date
Alan Schiller (909) 993-0340
Typed Name of Administrator Phone No. of Administrator
Claims Manager
· Title
Hazelrigg Risk Management Services
Name of Administrative Agency or Employer
(909) 627-3460 .
Fax No. of Administrator
aschiller(~hrmsyourtpmcom
E-mail Address of Administrator
Street Address
ci~: Chino
14275 Pipeline Avenue
State CA ziP+4 91710
Fiscal Year
01/02
NOTE: CI~.~ Admin£~tr~tor
Complete this page for each adjusting
location where them are at lca~t
two adjusting locations.
Reporting Location Nos.:
III. LIABILITIES BY REPORTING LOCATION
~H
!-'1-1 I I I I-I'-i-1-11 I !
Page 3
Fiscal year Ending June 30, 2002
Name/Identification of Location:
OR
Name of Affiliate/Subsidiary Certificate Holder:
Type of Report:
·
~-~ Original Report (Due October 1 each year) ~] Interim/Amended Report for the Period of:
I I I I Iiili"'] I I I I I I I
[ Mon~ Day Year to Monlh Day Year
CASES
BENEFITS
(to
nearest
dollar)
Incurred Liability Paid to Date Furore Liability
Numl~r $ Indemnity $ Mexiical $ Inde~mity $ Medical $ Indemnity $ Medical
2. Olin & Clos~i Cas~
Toralcasezmtx~ed
T°talca*~
& FY 2000-2001
T°talrepomdcazez
SUBTOTAL
3. ESTIMATED FUTURE LIABILITY (Indenmity plm Medical) TOTAL
$
M~lieal
5. Number of MEDICAL-ONLY cases reported in FY 2001-2002: ....................
6. Number of INDEMNITY cases reported in FY 2001-2002: ........................
7. TOTAL of 5 and 6 (also enter in 2e above): ...............................
8, TOTAL number of open indemnity cases (all years): ........................
9. Number of Fatality cases reported in FY 2001-2002: ........................
10. (a) Number of FY 2001-2002 clalmn for which the employer or adminintrator was
notified of representation by an attorney or legal representative in FY 2001-2002: ....
(b) Number of non-FY 2001-2002 claims for which the employer or admlni~a-ator was
notified of representaiion by an attorney or legal representative in FY 2001-2002: ....
Fiscal Year
0
Page~3 (Rew~'se Side)
IIIA. AD1VIINISTRATOR
A. NAME OF CURRF24T ADMINISTRATOR($)/ADMINISTRATING AGENCYOES) AT THE TIME OF PREPARING THIS REPORT.
1. Name (Person) .
·
Agency Name
Address
City State Zip+4
Adminigtrative Agency's
Certificate No.: ~
or ~-] SelfAdmini~ered
B. HAS THERE BEEN A CHANGE IN ADMINISTRATOR/ADMINISTRATIVE AGENCY DURING THE PERIOD OF
THIS REPORT PERIOD? [~]YES DNO IF YES, DATE OF CHANGE: [ I I I I .! I Mont~ Day Year
TYPE OF CHANGE: D Change in Admintgtrative Agency
[-~ Change to or from Self Admini~xatlon
C. NAME OF PRIOR ADMINISTRATOR(S)/ADMINISTRATIVE AGENCY(IES):
N~e
Agency Name
Address
," City State Zip+4
CERTIFICATION
I declare under penalty of perjury that I have prepared or caused this report to be prepared and I have e~smi~ed tl~
consolidated report of this self insurer's workers' compensation liabilities. To the best of my knowledge and belief this report
is true, correct and complete with respect to the workers' compensation liabilities incurred and paid. I further declare under
the penalty of perjury that the estimates of future liability of workers' compensation clnimn made in this report reflect the
administrator's best judgment as to the future liability of claims, using prevailing industry standards, and the signatory
intends Serf Insurance Plans to rely upon the representation.
Original Signature of Admini.qrator (Person)
Date
Typed Name of Administrator
Name of Administrative Agency or Employer.
Title Street Address
Phone No. of Administrator ( )
City
Fax No. (
state zips4
area code
E-mail Address of Admini.~trator
m'ea code
Fiscal Year
01/02
NOTE: Self Insured Employer
Complete this page on ALL reports.
IV. RECORDS STORAGE
1. Are claims records stored at any location other than with the current administrator?
~]Yes ~] No
A. Agency Name
Address
City
Phone ,,(
B. Agency Name
Address
citY
Phone ,(
If yes, Where?
C. Agency Name
Address
Page 4
Fiscal Year Ending June 30, 2002
City
Phone (
D. Agency Name
Address
State .. Zip+4 .. City
Phone
State _ Zip+4,
State Zip+4
V. INSURANCE COVERAGE
1. Are any of your workers' compensation liabilities in California during the reporting period
covered by a standard workers' compensation insurance policy?
[~] Yes ~-]No If Yes:
1. Name of Insurance Company:
Policy Number: Policy Issue Date:
2. Name of Insurance Company:
Policy Number: Policy issue Date:
2. Are any of your workers' compensation liabilities in California during the reporting period
covered by a specific excess workers' compensation insurance policy?
[~] Yes ~]No If Yes:
1. Name of Carrier: Employer's Reinsurance
Policy Number: 064 0750 Policy Issue Date:
Retention Lhnit:
5/1/01
2. Name of Carrier:
Policy Number:
Retention Limit:
Policy Issue Date:
3. Do you carry an aggregate (stop loss) workers' compensation insurance policy?
~ Yes ~-] No If Yes:
1. Name of Carrier:
Policy Number:
Retention Limit:
Policy Issue Date:
2. Name of Carrier:
Policy Number: Policy Issue Date:
Retention Limit:
VI. OPEN IN EMN1TY CLAIMS "
A. List of ALL Open Indemnity Claims by reportine location and by year reported and with claims in alphabetical
ox'der is attached immediately following page 6 of this report ....
(You may use the form attached or a comPuter, prepared printout
organized in the same formaL).
Fiscal Year
01/02
'V IL FUNDING OF LIABILITIES
Certificate Number: E]-1"7'1'1171 I-PTTI-I' 11614 I
Name of Certificate Holder: City of Tustin
Page 5
Fiscal Year Ending June 30, 2002
1. Which of the following best describes the method your agency uses to fund the outstanding workers' compensation liabilities?
~] Actuarial Basis
[~] Cash Flow Basis
[-'] Fixed Amount in Agency BudgetmAmount is: $
'-]Percentage Above Last Year's Losses--Percentage is: %
tTotal Amount Available is: $
[~] Agency Does Not Fund Workers' Compensation Liabilities
[-] Other:
2. Does your agency fund for incurred but not reported workers' compensation claims in addition to known or
reported claims?
PI1 Yes ["-1 No ffyes, Amount: $ $362,888
3. Is the workers' compensation funding restricted or set aside solely to pay the agency's workers'compensation liabilities?
n~Yes DNo
If yes, what was the amount set aside as of June 30, 2002.9 $ 1,423,000
4. Does your agency have an outside, independent claims auditor review your case reserve practices and general
claim.~ management.*
[~Y~ I--I~o
Ifyes, what was the date of the last such audit? As part of JPA
5. Does your agency have an outside, independent actuary to review future liability funding.9
If yes, what was the date of the last such review? 5/23/02
FiScal Year
01/02
Reporting Location No.:
Certificate Number:
Page 6
Page of Pages
LIST OF OPEN INDEMNITY CAsEs
AS OF
(Date)
All Cases on this Page are
For the Year
NAME OF MASTER CERTIFICATE HOLDER:
Name of Is~arefl or Deceased Date of Labor Code De~ription of Injury Paid to Date Estimated Futm-e Ifiability
(l.~t) (lrn~t Initial) Injury Sectm4~O
:
Sahry $ Indemnity $
(List Alphabetically withiu year)
See Attached
Listin~t
Fiscal Year
0