WC112 Rev 6/19 Page 1 of 2 COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT DIVISION OF WORKERS222 COMPENSATION for the period beginning January 1, 2019 and ending June 30, 2019 Do Not Alter this Address Address Change or Correction Note: All executive officers are to be reported under their classification at an individual payroll of $ 1, 087 .00 per w eek. Class No. Job Title Payroll Rate Premium Equivalent TOTALS American LegalNet, Inc. www.FormsWorkFlow.com WC112 Rev 6/19 Total Number Of Employees Total Payroll $ 1.Total Of Payroll Premium Equivalents$ 2.Premium Equivalent less Deductible, if applicable (see attachment 4), is the Subject Premium. Hazard Group Discounts: 1 = 32.9 %2 = 28.1 %3 = 25.8% 4 = 21.3 % 5 = 18.0 %6 = 15.4 % 7 = 13.2 % % $ 3.Subject Premium times NCCI Experience Mod = Modified Premium $ 4.Modified Premium times Rating discount of 10.0 % = Standard Premium$ 5.Surcharge Premium:The standard premium minus the discount described below is the Surcharge Premium. If standard premium (amount on line 4 above) is less than $100,000, discount is 9.1%;If standard premium is greater than $100,000 and less than $775,000, discount is 11.3%;If standard premium is greater than $775,000, discount is 12.3%.Standard premium minus this discount becomes the Surcharge Premium. %$ 6.Surcharge Premium times rate (1.45%) = surcharge due$ (The assessment of 1 . 45 % is the combined total of two separate surcharges: the Major Medical an d Subsequent Injury Funds at 0.1 0 %; and the Cash Fund at 1 . 35 %) We, the undersigned President and Secretary (or other chief officers or agents) of the corporation for which this return is made, being severally duly sworn, each for himself/herself, deposes and says that this return has been examined by him/her and is to the best of his/her knowledge, information and belief, a true, correct and complete return made pursuant to provisions of The Colorado Workers222 Compensation Act, Colorado Revised Statutes, Sections 8-44-112, 8-46-102 and 8-46-202. Notary Seal Corporate Seal President or Chief Officer Secretary or Chief Agent Subscribed and sworn before me this day of , Notary Public My commission expires Name of Contact Person Mail to: Division of Workers222 Compensation 633 17th Street, Suite 900 Denver, CO 80202 303-318-8767 F 303-318-8778 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com