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
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.
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Form AR-2 Addendum--Aggregate Claims Information [Proposed Data Fields for Online Submission] |
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| 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) | ||||||||
