OR, if not included in a risk pool or group rating for WC, use the paragraph below: Workers’ Compensation coverage is provided by the State of Ohio. The Cemetery pays the State Workers’ Compensation System a premium based on a rate per $100 of salaries. This rate is calculated based on accident history and administrative costs (if material). Can be deleted if immaterial. Commercial Insurance The Cemetery has obtained commercial insurance for the following Comprehensive property and general liability; Vehicles; and Errors and omissions. The Cemetery is uninsured for the following risks: Comprehensive property and general liability; Vehicles; and Errors and omissions. [Insert the following sentence if uninsured losses were material.] During 20CY, the Cemetery paid $XXX for losses that exceeded insurance coverage. [Also disclose any significant changes in coverage from the prior year. Risk Pool Membership The Cemetery is a member of the XYZ Self Insurance Pool (the Pool). The Pool assumes the risk of loss up to the limits of the [name of subdivision’s] policy. The Pool may make supplemental assessments if the experience of the overall pool is unfavorable. [Modify the preceding sentence as needed.] The Pool covers the following risks: General liability and casualty; Public official’s liability; and Vehicle. The Pool reported the following summary of assets and actuarially-measured liabilities available to pay those liabilities as of December 31: Self-Insurance The Cemetery is also self-insured for [describe type of coverage, such as employee health or liability insurance]. The Self-Insurance Fund pays covered claims to service providers, and recovers these costs from charges to other funds based on an actuarially determined cost per employee. [OR] Interfund rates are charged based on claims approved by the claims administrator. [OR] [describe other method of cost recovery]. A comparison of Self Insurance Fund cash and investments to the actuarially-measured liability as of December 31 follows:
[Note: The above is an embedded Excel Spreadsheet. Double-click to edit. Do not enter $ signs. Enter percentages as decimals, e.g., .0525 = 5.25%.] [Insert Principal Outstanding December 31, 20CY from the Amortization Schedule or Bank Schedule.] [List other indebtedness, such as leases, if material.] [Include a description of the debt, including amount, term, maturity date, interest rate, purpose, collateral, and any other significant information, such as defaults, etc.] [Example note disclosure] The Cemetery is obligated for a note payable to a bank. The note is payable over a period of five years at $500 per month plus interest charged at 75 percent of the bank’s prime variable rate, adjusted monthly. The rate disclosed above was the rate effective at December 31, 20CY. The property collateralizes the note. Substantially all the Cemetery’s real and personal property and receipts collateralize the Mortgage Revenue Bonds. [Briefly describe other material debt issues, too. Describe collateral pledged (e.g., pledged receipts, a mortgage on the property financed, taxing authority (that is, general obligations), uncollateralized) and other significant matters, including defaults, covenant violations, etc. Describe any defeased debt and the amounts outstanding, but explain the defeased amounts are NOT included in the amortization table below. Amortization of the above debt, including interest, is scheduled as follows: [Note: The above is an embedded Excel Spreadsheet. Double-click to edit. Do not enter $ signs.] [Insert amounts by debt type from amortization schedules. Present amounts due after five years in 5-year increments.] Should your Cemetery have any additional debt including leases for buildings, vehicles, and/or equipment, you should insert the appropriate description and make any other necessary footnote and financial statement modifications. The Generic Special Purpose Government Notes shell provides examples in Note 11 that can be used and you can cut and paste into this example. Note 12 – Construction and Contractual Commitments Identify any potentially significant outstanding construction or other contractual commitments. Note 13 – Contingent Liabilities