Illinois Administrative Code
Title 50 - INSURANCE
Part 928 - MEDICAL PROFESSIONAL LIABILITY DATABASE
Exhibit E - Supplement A to Schedule T Reconciliation Form
SCHEDULE T DATA RECONCILIATION FORM
Company Name: |
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Line Number |
Line |
Loss paid - number of claims |
Losses paid - dollar amount |
1 |
Schedule T, Supplement A |
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2 |
Part 928 claim report totals |
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3 |
Difference (line 1 - line 2) |
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Adjustments to Schedule T |
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4 |
Sch T - payments reported in current year on claims closed in prior years |
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5 |
Sch T - claims not reported in Part 928 claims data for other reasons (claim not reportable in this State, etc.; specify in separate explanation) |
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6 |
Correction for other discrepancies (occurrence vs. claims reporting, other accounting issues, etc.; specify in separate explanation) |
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7 |
Adjustments to Schedule T (line 1 - line 4 - line 5 - line 6) |
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Adjustments to 928 Claims Data |
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8 |
Claims not reported on Schedule T for other reasons (reported for another state, etc.; specify in separate explanation) |
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9 |
Other adjustments needed for claims data to reconcile to Schedule T |
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10 |
Adjustments to claims data (line 2 - line 8 - line 9) |
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Reconciled Amounts |
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11 |
Difference in adjusted amounts (line 7 - line 10) - this line should equal 0. |
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Explanation for adjustments on line 5: |
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Explanation for adjustments on line 6: |
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Explanation for adjustments on line 8: |
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Explanation for adjustments on line 9: |