Free K-WC 20 - Bank Fact Sheet (Rev. 02-07) - Kansas

Date:_______________________________________ Submit To: DIVISION OF WORKERS COMPENSATION DEPARTMENT OF LABOR 800 SW JACKSON STE 600 TOPEKA KS 66612-1227 [email protected]

BANK FACT SHEET



Name of Requesting Self-Insured Company(ies): Name of Parent Bank:
(IfParentalRelationshipExists,PROVIDEULTIMATEPARENTDATAONTHISFACTSHEETASWELLASULTIMATEPARENTFINANCIALS.)

Bank Name: Address:

Contact Name: Telephone Number: Financial Summary as of: Equity: Deposits: Loans/Discounts: Cash and Due from Bank: Securities: Total Assets:

OperatingRatios: ROA: ROE: Loan Loss Provision/Average Loans: Net Losses/Avg. Loans: Loan Loss Reserve/Year-end Loans: Loan Loss Reserve/Non-Performing Assets:

Ratings: Thompson Bank Watch: Standard & Poors: Moody's: Sheshunoff: CapitalAdequacy: Capital to Weighted Risk Assets: Percent of Core Capital (Tier 1): Attachacopyoftheannualreportorcallreport.

Authorized Signature: Type Name and Title:
K-WC 20 (Rev. 2-07)