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Safety National » Request for Reimbursement – Aggregate Excess

Request for Reimbursement – Aggregate Excess

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Loss Fund
(a)

Minumum Term Loss Fund (MTLF)

(b)
MM slash DD slash YYYY

Minus Paid over Self-Insured Retention(s)

(c)
Total Paid Applicable to Loss Fund
Minus Assessments, SDF or other exclusions
Net Paid Applicable to Loss Fund
Minus Greater of Loss Fund or MTLF (a) or (b)
Amount of Aggregate Claim
Minus Previous Safety Reimbursements
Amount Requested
Loss run summary must be attached to process reimbursement which supports figures above including paid amounts over specific Self-Insured Retention (c)

  • Loss run summary must be attached to process reimbursement which supports figures above including paid amounts over specific Self-Insured Retention (c)
Drop files here or
Max. file size: 256 MB, Max. files: 10.

    Sworn Statement in Proof of Loss

    The undersigned, as the designated representative for the above Named Insured, states that the above figures are true and correct. Any statements attached hereto are made part of this instrument.

    MM slash DD slash YYYY
    Name*
    Address*

    Bank/Reimbursement Information

    Reimbursement Method
    Bank Address*
    Company Address
    This is the address your check will be sent to.