Free 1 - Vermont

State of Vermont
Workers' Compensation Administration Fund

QUARTERLY ASSESSMENT STATEMENT
FOR QUARTER ENDING

Insurer: Group: Federal Tax ID Number (Insurer):

NAIC Company Code: NAIC Group Code:

1. 2. 3. 4. 5.

Total estimated direct premiums written for the quarter being reported: Assessment due (Line 1 X .0081): Prior quarter (over) & under payments (explain on reverse, if necessary): Balance Remitted (Line 2 minus Line 3): - or Credit to be subtracted from next payment:

$ $ $ $ $

Make checks payable to:

Vermont Department of Labor Workers' Compensation Administration Fund 5 Green Mountain Drive, PO Box 488 Montpelier, VT 05601-0488

The foregoing is an accurate estimate of direct written premiums for the period indicated.

(Signature)

(Date)

Name: Title: Email:

Telephone: Fax:

Address:

WCAF Form 2, 01/05

.4% Assessment