Appendix II





 

MINNESOTA AUTOMOBILE ASSIGNED CLAIMS PLAN
APPENDIX III

TO: Minnesota Automobile Assigned Claims Bureau
PO Box 247
227 Central Avenue, Suite 103
Osseo, MN  55369

DATE
t

REPORT FOR THE PERIOD ENDING

t

In accordance with the Rules and Regulations of the Assigned Claims Plan, the undersigned Servicing
Insurance Carrier submits a reporting of the status as of t
of the cliams previously assigned by the Plan.

The person signatory hereto certifies on behalf of this company that all statements are complete and correct in accordance with the company's records.
t


Name of Reporting Company:

t

By:

t

Address:
t

 

(1)

(2)

(3)

(4)

(5)

(6) (7) (8) (9) (10) (11) (12)

Assignment Control #

Company Claim #

Date of Acc.

Medical Loss Wage Loss Survivor's Loss Funeral & Burial
Expenses
Replacement Services Loss Aallocated Claim Exp. Subrogation Recovery Net Paid Loss
(4+5+6+7
+8+9)-10
Reserve for O/S Loss
t t t t t t t t t t t t
t t t t t t t t t t t t
t t t t t t t t t t t t
t t t t t t t t t t t t
t t t t t t t t t t t
t t t t t t t t t t t t

ACP-3

Revised July 1, 1993

Appendix III

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Last updated: Sunday, February 27, 2002
2001 Minnesota Automobile Assigned Claims Bureau
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