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 1 Total premium written on Colorado Workers222 Compensation Insurance policies with deductibles less than $17,000, including excess coverage 205205205205205205205205205205205205205205. $ 2 Plus premium on deductible policies over $ 17,0 00 , reported on a $ 17,0 00 deductible basis 205... $ 3 Less total canceled or returned premiums 205205205205205205205205205205205205205205205205205205205205205. $ 4 Net premiums subject to surcharge 205205205205205205205205205205205205205205205205205205205205205205205... $ 5 Net amount of Surcharge ( 1.45 % of net premiums) 205205205205205205205205205205205205205205205205205. $ (The assessment of 1.45 % is the combined total of three separate surcharges: the Major Medical an d Subsequent Injury Funds at 0.10%; the Cash Fund at 1.35%; and the Premium Cost Containment Fund at 0.0 %.) We, the undersigned President and Secretary (or other chief officers or agents) of the corporation for which this return is m ade, 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 to before me this day of , FEIN Block # Notary Public My commission expires NAIC # Mail to: Division of Workers222 Compensation 633 17th Street, Suite 900 Denver, CO 80202 Ph: 303-318-8767 F: 303-318-8778 WC113 Rev 6/19 Name of Contact Person (print) American LegalNet, Inc. www.FormsWorkFlow.com