2010 ASSESSMENT REPORT FOR INSURANCE COMPANIES, SELF-INSURERS & GROUP FUNDS STATE OF ALABAMA DEPARTMENT OF INDUSTRIAL RELATIONS WORKERS’ COMPENSATION DIVISION 649 Monroe Street Montgomery, Alabama 36131 Telephone: (334) 242-2868 Toll Free 1-800-528-5166 January 1, 2011 COMPANY NAME CONTACT PERSON MAILING ADDRESS PHYSICAL ADDRESS CITY ST ZIP FEIN: NCCI #: SI #: SI-0 Group Fund #: GTelephone #: Email: Email Address SUBSIDIARIES OF SELF INSURED COMPANIES: In accordance with the Alabama Workers’ Compensation Law, Title 25, Code of Alabama, 1975, § 25-5-316(d) - § 25-5-317as last amended, this report is to be filed with the State of Alabama on or before the first day of March each year. The total expenses reported will be used in the calculation of your annual assessment. DO NOT INCLUDE NEGATIVE AMOUNTS. DO NOT DEDUCT SUBROGATION OR REINSURANCE/EXCESS RECOVERABLES Compensation Paid: $ 0.00 Medical Paid: $ 0.00 Administrative Expenses Paid: $ 0.00 Attorney Fees Paid: $ 0.00 Court Settlements: $ 0.00 CERTIFICATION UNDER PENALTY OF PERJURY, I, Person Certifying Form, being duly sworn, dispose, affirm, and verify that the foregoing is a true and correct report of workers’ compensation payments made in accordance with the Alabama Workers’ Compensation Law, as last amended. I further verify and affirm that this report constitutes a true and correct report of payments made by all operations with the state. I understand that the monetary figures and sums certain contained therein will be used to compute the workers’ compensation assessment due and payable to the Alabama Workers’ Compensation Administrative Trust Fund. I further verify and affirm that I am a duly appointed official of Company Certifying Losses in the capacity of Certifying Person's Title and that I am duly qualified and authorized to sign this report. Title: , Certifying Person: Sworn to and subscribed before me this Notary Public: WCC10 day of , 2011. Commission Expires: Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com