Free State of Vermont - Vermont

State of Vermont
Workers' Compensation Administration Fund

QUARTERLY ASSESSMENT STATEMENT
DUE: October 31, 2009; January 31, 2010; April 30, 2010 and July 31, 2010 FOR QUARTER ENDING Insurer: Group: Federal Tax ID Number (Insurer): 1. 2. 3. 4. 5. Total estimated direct premiums written for the quarter being reported: Assessment due (Line 1 X .0096): 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: $ $ $ $ $ NAIC Company Code: NAIC Group Code:

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) Name: Title: Email: Address: Telephone: Fax:

(Date)