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Vermont Department of Labor

Workers' Compensation Administration Fund

Insurer's Reconciliation Statement
Calendar Year: 2006
Group Name: Company Name: NAIC Group Code: NAIC Company Code:

1. Direct Premiums Written
Enter the amount of direct premiums written during the period January 1, 2006 through December 31, 2006 This amount should equal what is reported to the Vermont Department of Banking, Insurance, Securities & Health Care Administration (BISHCA), on the company's annual statement. [Exhibit of Premiums and Losses (Statutory Page 14 Data), Line 16, Column 1] 1.

2. Annual Assessment Due
The Vermont General Assembly establishes the assessment rate annually. The current assessment rate is .4%. Multiply the amount on line 1 by .004. This is the total annual assessment due. 2.

3. Quarterly Assessments Previously Submitted
Enter the quarterly assessments actually submitted throughout calendar year 2006. Note: negative amounts (credits) SHOULD NOT be listed here, with the exception of the amount carried forward.] Amount carried forward from 2005 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter TOTAL AMOUNT PREVIOUSLY SUBMITTED 3.

4. Balance Due
Subtract line 3 from line 2. If the amount is greater then 0, this is the remaining assessment amount due. If the amount is less than 0, enter the amount on Line 5. iiMake Checks Payable to: Vermont Department of Labor Forward check, and this form, to: Workers' Comp Admin Fund PO Box 488 Montpelier VT 05602 AMOUNT DUE

4.

5. Credit to be applied to next quarterly submission or Amount to be refunded
If line 5 is less then zero, this amount will carry-forward and be credited towards the next quarterly assessment due. Alternatively, this amount may be refunded if requested. CREDIT 5.

6. Certification
I certify that the information identified above, and submitted, is true and accurate.
(Signature) (Date)

Name: Title: Group Address:

Telephone: Email: Company Address:

Include a copy of "Exhibit of Premiums and Losses (Statutory Page 14 Data)" with your submission

WCAF Form 1, 01/05