California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 8 - Office of the Director › Subchapter 2 - Administration of Self-Insurance Plans › Article 2 - Certificate of Consent to Self-Insure › Appendix - Appendix

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Terms used in Public Self-Insurer Report Forms P-1 and
						J-1 (§
											15203.11) and AR-2 (§
											15251(c))
The definitions in section
						15201 of the Self-Insurance Plan
						regulations (Title 8, California Code of Regulations §
											15201) apply to the terms used in
						these reporting forms. All terms shall be construed in a manner that is
						consistent with their usage in Division 4 (commencing with Section
						3700) of the Labor Code and
						Chapters 1 (commencing with section
						1), 4.5 (commencing with section
						9700), and Subchapter 2 of Chapter
						8 (commencing with section
						15201) of Division 1 of Title 8 of
						the California Code of Regulations, including any definitive construction of a
						term by the Workers' Compensation Appeals Board or a court. However, if there
						is a conflict between a definition in section
						15201 and a definition of the same
						terms found in another Title 8 regulation, the definition in section
						15201 shall apply.
Terms that are not defined by statute or regulation
						should be understood as having the same meaning commonly understood and used by
						workers' compensation program administrators in the state of California. A good
						faith error or discrepancy in how reportable information is characterized for
						purposes of one of these reports shall not be treated as a reporting violation
						under Labor Code Sections
						3702.3 or
						3702.9.
The following additional guidance is provided for
						specific report terms.
Allocated Loss Adjustment Expense
or
ALAE
means claim administration costs and expenses that are
						allocated to individual workers' compensation claims, including but not limited
						to medical cost containment expenses.
Catastrophic claim
means a claim for
						workers' compensation based on a severe injury to the brain or spinal cord,
						loss of a limb, paralysis, severe burn or severe head injury, and includes any
						injury that would result in a conclusive presumption of total disability under
						Labor Code Section
						4662(a).
Certificated employee
has the same meaning
						used in the Education Code and refers to an employee in an academic,
						supervisory, or administrative position with a school or school district,
						community college or community college district, or state university who is
						required to hold a credential or similar certificate as a condition of
						employment.
Classified employee
has the same meaning
						used in the Education Code and refers to an employee of a school or school
						district, community college or community college district, or state university
						who is not a certificated employee.
Diagnostics
refers to medically-prescribed
						tests used to determine a diagnosis, the cause of symptoms, the nature or
						severity, or course of treatment for an illness or injury. It includes but is
						not limited to imaging and laboratory tests.
Full-Time Equivalent
or
FTE
refers to the ratio of the total number of paid hours for all employees,
						whether full or part-time, divided by the number of hours in the employer's
						regular full-time work week. If the employer has a regular work week of 40
						hours and 10 employees working a total of 200 hours during a regular work week,
						the full-time equivalent or FTE would be 5. (200 / 40 = 5).
Industrial Disability Leave
claims and
						benefits refers to salary-based payments made to public employees in lieu of
						workers' compensation temporary indemnity benefits pursuant to Education Code
						Section
						45192,
						Education Code Section
						89529.03,
						Government Code Section
						19871, or
						equivalent statutes or employer policies governing compensated absences for
						job-related illnesses or injuries, insofar as those payments are categorized
						separately from other types of indemnity payments. For reporting purposes,
						Industrial Disability Leave claims and benefits
do not include
salary continuation benefits provided to Public Safety Employees pursuant to
						Articles 6 and 7 (commencing with Sections
						4800 and
						4850 respectively) of Chapter 2 of
						Part 2 of Division 4 of the Labor Code, even if designated Industrial
						Disability Leave by the employer. Those payments instead should be reported as
						Public Safety Employee claims and benefits.
Public Safety Employee
means an employee of
						a fire department, police or sheriff's department, or other public protection
						or public safety agency who is entitled to receive salary continuation benefits
						in lieu of workers' compensation benefits pursuant to one or more statute
						within Articles 6 and 7 (commencing with Sections
						4800 and
						4850 respectively) of Chapter 2 of
						Part 2 of Division 4 of the Labor Code. For reporting purposes, employees of
						the California State University Police Department who are entitled to enhanced
						Industrial Disability Leave benefits pursuant to Labor Code Section
						4816, shall be
						counted as "public safety employees," including for public safety employee
						payroll purposes, and their claims and benefits payments should be reported as
						public safety employee claims and benefits payments, even if designated by the
						employer as Industrial Disability Leave claims and benefits payments.
Surgery
refers to payments made to surgeons,
						assistant surgeons, anesthesiologists, and other medical personnel for surgical
						services that are billed and paid for separately from facility costs. It does
not
include hospital and facility expenses.
Unallocated Loss Adjustment Expense
or
ULAE
means claim administration costs and expenses that are not
						allocated to individual workers' compensation claims.
Volunteer
means a person who provides
						volunteer services for the employer and includes persons for whom the employer
						has elected to provide workers' compensation coverage pursuant to Labor Code
						Section
						3361.5,
						3363.5,
						3364,
						3364.5,
						3364.55,
						3364.6,
						3364.7, or
						equivalent statutes. The number of persons, if any, who are
neither
employees or volunteers, but for whom the employer is
						required to provide workers' compensation when participating in court-ordered
						community service, work for relief, or similar reasons should be estimated
						separately and entered on the line provided for that purpose in the Profile
						section (Part B) of the P-1 and J-1 forms.
Form AR-2 Addendum--Aggregate
								  Claims Information [Proposed Data Fields for Online Submission]
INJURY
								DATES
FY 19-20
FY
								18-19
FY 17-18
FY 16-17
FY 15-16
Years prior to
								FY 15-16
Number of New Notices of Representation
								Received in FY
Total number of open claims in each
								category as of the end of the reporting period. (Individual claims that fit
								into more than one category should be included in the count for each category
								that applies.)
Indemnity
								Claims
Medical-Only Claims
Future Medical Claims
Public Safety Employee
								Benefit Claims
Industrial Disability Leave
								Claims
Industrial Disability Leave
								Claims
Fatality Claims
Aggregate amount of benefits paid for
								each disability category
Temporary Disability Benefits
								Paid ($ amount)
Number of Claims where TD
								benefits were
								provided
Public Safety Employee
								Benefits Paid ($ amount)
Number of Claims where Public
								Safety Employees received salary continuation
								benefits
Industrial Disability Leave
								Benefits Paid ($
								amount)
Number of claims where Industrial
								Disability
Leave benefits were
								provided
Permanent Disability Benefits
								Paid ($ paid in permanent total and permanent partial
								disability)
Number of Claims where PD
								benefits were paid
Supplemental Job Displacement
								Benefits Voucher paid ($
								amount)
Number of Claims where SJDBV
								was issued
Death Benefits Benefits Paid,
								including burial costs ($
								amount)
Number of Claims were death
								benefits were
								provided
Aggregate amount of Medical Costs paid
								for each category
Interpreters ($
								amount)
Physician Visits ($ amount)
In-Patient Hospital ($
								amount)
Out-Patient Hospital and
								Ambulatory Surgery
Center ($ amount)
Diagnostics ($ amount)
DME supplies ($ amount)
Physical Therapy ($ amount)
Pharmaceutical ($ amount)
Surgery ($ amount)
In Home Support ($ amount)
Medical-Legal ($ amount)
All other Medical Costs not
								included above ($ amount)
Aggregate amount of Legal and Loss
								Adjustment Expenses for each category
Attorney Fees and Legal Costs
								($ amount)
Photocopy Fees ($ amount)
Interpreter's Fees ($ amount)
Medical Cost Containment
								Fees--total ($ amount)
Bill Review, including IBR--total
								($ amount)
Utilization Review ($
								amount)
Independent Medical Review ($
								amount)
Uncategorized Legal and Loss
								expenses or any other Legal and Loss Expenses not included above ($
								amount)
Estimated Future Liabilities:
								(
Estimate of total incurred costs, less paid
) - OPEN CLAIMS
								ONLY
Temporary Disability ($
								amount)
Permanent Disability ($
								amount)
Public Safety Employee
								Benefits ($ amount)
Industrial Disability Leave
								Benefits ($ amount)
Supplemental Job Displacement
								Benefits
Voucher ($ amount)
Death Benefits ($ amount)
Medical Costs ($ amount)