SI03 (Revised 09/2018)
Central Services Division
Vehicle Programs
555 Wright Way
Carson City, Nevada 89711
(775) 684-4491
Email: DMVSelfInsurance@dmv.nv.gov
SELF-INSURANCE LOSS EXPERIENCE RECORD
(NAC 485.060 and NAC 485.110)
Self-Insurance Applicant
Assigned Certificate Number
(If new applicant, please leave this space blank.)
In accordance with NAC 485.110, “the self-insurer shall annually submit a report on a form provided by the Department
indicating the number of accidents, the number of claims submitted to be paid by the self-insurer, the amount of each claim,
the amount paid to a claimant if the claim has been adjudicated and the adjusting companies which have settled claims on
behalf of the self-insurer.”
The self-insurer must provide records of annual costs of claims during the immediately preceding 3-year period; complete a
SEPARATE FORM FOR EACH YEAR. Additionally, complete records, including detailed information for each claim, must
be attached for each year.
What was the TOTAL NUMBER OF ACCIDENTS for this reporting year?
What was the TOTAL NUMBER OF CLAIMS submitted to be paid by the self-insurer for this reporting year?
What was the TOTAL DOLLAR AMOUNT OF ALL CLAIMS for this reporting year? $
What was the TOTAL DOLLAR AMOUNT PAID TO CLAIMANT(S) for this reporting year? $
Submitted
Has This Claim
Amount Paid
Name of Adjusting Company
(Use additional sheets if needed.)
Yes No* Were all claims settled by the above-named self-insurer?
*If the above-named self-insurer did not settle all claims, complete the Adjusting Company Affidavit (Form SI-04).
NOTE: TO BE SIGNED ONLY BY INDIVIDUAL, SOLE PROPRIETOR, PARTNER, OR OFFICER OF THE CORPORATION.
I hereby certify all statements made in this report are true and correct. I fully understand false statements are cause for
cancellation of the Certificate of Self-Insurance. I understand that this report must be filed annually no earlier than 60 days before
and no later than 15 days before the date of expiration of the Certificate of Self-Insurance.
Printed Name Title
Signature Date Signed
NOTARIZATION: Date Notarized
State of , County of
I certify that on the date set forth below, the individual named above did appear
personally before me and that I did identify this individual. The statements on this
document are subscribed and sworn to before me by the endorsee on this
day of , .
Notary Public Signature:
My Commission Expires:
