Free Vermont Department of Labor - Vermont

Vermont Department of Labor Calendar Year:
Group Name: Company Name:

Workers' Compensation Assessment Fund 2009 DUE:
NAIC Group Code: NAIC Company Code:

Insurer's Reconciliation Statement
March 15, 2010

Did the company name change during calendar year 2009? Yes No New Company Name: Yes No New Group Number: Did the group number change? During calendar year 2009 was this company involved in a merger? Yes No If yes, what other NAIC codes were involved? 1. Direct Premiums Written Enter the amount of direct premiums written During the period January 1, 2009 through December 31, 2009 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, 2009 to June 30, 2009 is .81% The assessment rate from July 1, 2009 to December 31, 2009 is .96% Multiply the amount on line 1 that was written between January 1, 2009 and June 30, 2009 by .0081. Multiply the amount on line 1 that was written between July 1, 2009 and December 31, 2009 by .0096. This is the total annual assessment due. 2. 3. Quarterly Assessments Previously Submitted Enter the quarterly assessments due by quarter throughout calendar year 2009. Amount carried forward from 2008 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter TOTAL AMOUNT DUE 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, 2009 ­ March 31, 2009 April 1, 2009 ­ June 30, 2009 July 1, 2009 ­ September 30, 2009 October 1, 2009 ­ December 31, 2009

(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