Free Vermont Department of Labor - Vermont

Vermont Department of Labor Calendar Year: DUE:
Group Name: Company Name: 1. Direct Premiums Written Enter the amount of direct premiums written During the period January 1, 2007 through December 31, 2007

Workers' Compensation Assessment Fund 2007 March 15, 2008
NAIC Group Code: NAIC Company Code:

Insurer's Reconciliation Statement

This amount should equal what is reported to the Vermont Department of Banking, Insurance, Securities and 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 assessment rate form January 1, 2007 to June 30, 2007 is .4% The assessment rate from July 1, 2007 to December 31, 2007 is .42% Multiply the amount on line 1 that was written between January 1, 2007 and June 30, 2007 by .004. Multiply the amount on line 1 that was written between July 1, 2007 and December 31, 2007 by .0042. This is the total annual assessment due. 2. 3. Quarterly Assessments Previously Submitted Enter the quarterly assessments actually submitted throughout calendar year 2007. NOTE: Negative amounts (credits) SHOULD NOT be listed here, with the exception of the amount carried forward. Amount carried forward from 2006 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter TOTAL AMOUNT PREVIOUSLY SUBMITTED 4. Balance Due Subtract line 3 from line 2. If the amount is greater than 0, this is the remaining assessment amount due. If the amount is less than 0, enter the amount on Line 5. Make Checks Payable to: Vermont Department of Labor Forward check, and this form, to: Workers' Compensation Admin Fund PO Box 488 Montpelier, VT 05601-0488 AMOUNT DUE 4. 5. Credit to be applied to next quarterly submission or Amount to be refunded If line 5 is less than zero, this amount will carry-forward and be credit 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. 3. January 1, 2007 ­ March 31, 2007 April 1, 2007 ­ June 30, 2007 July 1, 2007 ­ September 30, 2007 October 1, 2007 ­ December 31, 2007

(Signature) Name: Title: Group Address:

(Date) Telephone: Email: Company Address:

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