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MINNESOTA AUTOMOBILE
ASSIGNED CLAIMS PLAN
APPENDIX III
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Minnesota Automobile Assigned Claims Bureau
PO Box 247
227 Central Avenue, Suite 103
Osseo, MN 55369 |
DATE |
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REPORT FOR THE PERIOD ENDING |
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| 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 |
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| of the cliams previously assigned by the Plan. |
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The person signatory hereto certifies on behalf of this company that all statements
are complete and correct in accordance with the company's records.
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Name of Reporting Company:
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By: |
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Address: |
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(1) |
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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 |
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ACP-3 |
Revised July 1, 1993 |
Appendix III |
Last updated:
Sunday, February 27, 2002
�2001 Minnesota Automobile Assigned Claims Bureau
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