Public Self Insurers ER Annual Report

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Bertha Ray
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1 State Of California Public Self Insurers ER Annual Report For Year 2012/2013 September 30,2013 Desert Community College District Monterey Ave Palm Desert CA

2 Employer General Information : Certification Number 7634 Period Of Report Full Year (Period) From- 07/01/2012 (Period) To 06/30/2013 Master Certificate Holder : FTIN Name Desert Community College District Address Monterey Ave City- Palm Desert State CA Zip Type of Public Agency School Subsidiaries : No Subsidiaries Added During the reporting period of this report, has there been any of the following with respect to the Master Certificate Holder or any subsidiary? A merger or unification? (No) Changes in name or identity? Identity (No) Any addition to Self Insurance Program Insurance Program (No) If Yes, Explain : N/A Employment and wages paid in current calendar year : Number Of Employees 715 Total Wages And Salaries Paid $29,490,967 Addressed Correspondence For Security Deposit and Financial Matters : Name - Wade W Ellis Position/Title - Director Fiscal Services Company Name - Desert Community College District Address - wellis@collegeofthedesert.edu Phone Number ex Fax Number Address Monterey Ave. City - Palm Desert State- CA Zip Corporate Web Address - Collegeofthedesert.edu

3 Record Storage : Are Claim records stored at any location other then with the current administrator? (Yes) 1) Iron Mountain 1760 North St. Thomas Circle Orange, CA Phone ex Insurance Coverage : Are any of your workers' compensation liabilities in California during the reporting period covered by a standard workers' compensation Insurance policy? (No) Are any of your workers' compensation liabilities in California during the reporting period covered by a specific excess workers' compensation Insurance policy? (No) Do you carry an aggregate (stop loss) workers' compensation insurance policy? (No)

4 Name Of Company Officer- Street Address- Name Of Company- Wade W. Ellis, CPA Monterey Ave. College of the Desert City- Palm Desert State - CA Zip Phone Number ex Name Of Person Legally Responsible For This Electronic Signature : Wade W. Ellis, CPA ( Date/Time Of Signature ) - 09/30/ :36

5 Files Uploaded:

6 TPA:- Liabilities By Reporting Location Report Location Number: Identification of Location: Certificate Holder: Keenan & Associates - Riverside Desert Community College District CASES AND BENEFITS (to the nearest dollar) From Date- 07/01/2012 To Date- 06/30/2013 Date # Incurred Liability Paid To Date Future Liability Indemnity Medical Indemnity Medical Indemnity Medical 1) Cases as of 06/30/2013 reported prior to 2008/ , , , ,299 57, ,951 2) Open and Closed Cases A) All Cases reported in 2008/ /2009 Cases B) All Cases reported in 2009/ /2010 Cases C) All Cases reported in 2010/ /2011 Cases D) All Cases reported in 2011/ /2012 Cases E) All Cases reported in 2012/ /2013 Cases 32 3,383 69,644 3,383 69, , , , ,242 7,899 78, , ,273 92,816 81,211 7,899 78, , , , ,804 41, , , ,890 58,567 84,156 41, , ,140 3,301 4,140 3, $ Indemnity $ Medical SUBTOTAL 106, ,747 3) Estimate Future Liability (Indemnity Plus Medical) TOTAL 543,283 $ Indemnity $ Medical 4) Total Benefits Paid During 2012/2013 (Including all case expenditures) 84, ,538 5) Number of MEDICAL-ONLY Cases Reported in 2012/ ) Number of INDEMNITY Cases Reported in 2012/ ) Total of 5 and 6 (Also entered in 2E above) 0 8) Total Number of Indemnity Cases (All Years) 8 9) Number of Fatality Cases Reported In 2012/ ) (a) Number of FY 2013 claims for which the employer or administrator was notified of representation by an attorney or legal representative in ) (b) Number of non-fy 2013 claims for which the employer or administrator was notified of representation by an attorney or legal representative in ) Attach a List of ALL Open Indemnity Claims (by reporting location and by year) reported and with claims (in alphabetical order) 0 0 Desert CCD SIP A Open Indemnity pdf

Certification First Name Middle Name Last Name Agency Name Josie Thompson Keenan & Associates Address 1 City State Zip Code 4204 Riverwalk Parkway, Suite 400 Riverside CA 92505 Administrating

7 Certification First Name Middle Name Last Name Agency Name Josie Thompson Keenan & Associates Address 1 City State Zip Code 4204 Riverwalk Parkway, Suite 400 Riverside CA Administrating Agency's Certificate Number 062 Or Self Administered CERTIFICATION I declare under penalty of perjury that I have prepared or caused this report to be prepared and I have examined this liabilities report of this self insurer s worker s compensation liabilities. To the best of my knowledge and belief this report is true, correct and complete with respect to the worker s compensation liabilities incurred and paid. I further declare under the penalty of perjury that the estimates of future liability of worker s compensation claims 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 Self Insurance Plans to rely upon the representation. First Name M.I. Last Agency Name Josie Thompson Keenan & Associates Address Riverwalk Parkway, Suite 400 City State Zip Code Address Riverside CA jthompson@keenan.com Phone Number FAX Number Date Signature (Type your Full Name) ex /24/2013 jthompson@keenan.com Person legally responsible for this Electronic Signature

8 Files Uploaded: 1)Desert CCD SIP A Open Indemnity pdf Form A4-40a (Rev. 6/2001)

Zip Code FORM 1. (03) 4. (e) Type of Claim 54,337 54,337 FORM 1. (14) 54,337 FORM 1. (15)

Zip Code FORM 1. (03) 4. (e) Type of Claim 54,337 54,337 FORM 1. (14) 54,337 FORM 1. (15) Office COLLECTIVE BARGAINING AND COLLECTIVE BARGAINING AGREEMENT CLAIM FOR PAYMENT Claimant Identification NUmber 33025 Program Number 00232 Date Filed ) LRS Input Claimant Name DESERT COMMUNITY COLLEGE