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/#RQM Ot~01-B3 TO 12-12-88 ) V--------- ------------- A* .-------- ^
DECEMBER 19, 1BS3
J. H. ALEXANDER
FOR MANUFACTURING CO. A A L E X A N 0 S R - N E N YORK
ACCOUNT
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COVERAGES LOADED IN HISTORY
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II INA COVERAGES --
ID WORKERS COMPENSATION-INA
2D GENERAL LIABILITY-INA
SO AUTOMOBILE LIABILITY-INA
AO AUTO PHYSICAL DAMAGE-ENA
14 ESIS COVERAGES
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43 GENERAL LIABILITY-ESIS
33 AUTOMOBILE LIABILITY-ESIS
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J. M. MANUFACTURING CO. ALEXANDER A ALEXANDER-NEW YORK
PINAL CLAIMS ARC NOT LISTED SO DAYS AFTER LAST ACTIVITY
CLAIMS MANAGEMENT SYSTEM MASTER PILE PROM 01-01-85 TO 12-19-88 AS DP 12-1R-S8
ACCIDENT LOCATION
DATE
CODE
CLAIMANT NAME
LOCATION OR PRODUCT
DESCRIPTION Of ACCIDENT
20 GENERAL LXA9ILITY-ESIS
LINE 1 OPEN RESERVE, CLOSED TOTAL CLAIM OUTSTANOINS CAWS L ST
LINE 2 OPEN CASE TOTAL PAID TO DATE *
CARR A
' BI LIAS PS LIAS EXPENSE NET CLAIM OUTSTANDING
01-01-8*
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A-
- - - - 5.000.00
0aa/10t4?O1Oa/A INJ.-TO LUNCH PROM EXP. TtTASBEST^S-AS EMPL OF
01-01-84
SSSS'mROCZKA ''
U - - - - - y-'-S' - -`000.00
0B0/1BI47O109T/A~'DECEDANT DIED (0/2/79 ALLEQ.OUE Tp -- .....-,v
01-01-84
9995 vERMEULEN'*
J-
08B/iai*701098/A'M>LNTF.ALLEaED LUNQ INJ ^rTaAiS9EST0S>EXP.EMPL.J
5.000.00
01-01-84 TO 01-01-85 TOTALS FOR COVERAGE 25
NUMBER
BI LIAS
TOTAL CLAIMS - INCURRED AMOUNT CLDSED CLAIMS - TOTAL PAID TO DATE OPEN CLAIMS - TOTAL PAID TO GATE OPEN CLAIMS - OUTSTANDING RESERVES
3 15,000.00
,0 .00
5 .00 5 19 000.00
.00 0,500.00' 15,054.14 5,000.00 253A 1 CA
8,064.14- 8,094.1*
200'
.00 8,020.00 It.573.75 5.000.00 253A CA
8,BT3.T5 6,875.75
200
,00 .00 5.000.00 5.000.00 233A 1 CA 200
PD LIAB
EXPENSE
NET CLAIM OUTSTANDING
.00 14.727.S8 29,727.89 .00 .00 .00 .00 14,727.89 14,727.89
.00 '.00
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51TB1 >. M. MANUFACTURING CO. CA STATE
COVERAGE 23 01-01-8* TO 01-01-85 AS OF 12-19-Bfl STATE PAGE BREAK-DATE PAGE 5 B