QUARTERLY PREMIUM SURCHARGE PAYMENT FORM Insurer Name__________________________________________________________________ Address_______________________________________________________________________ City____________________________ State_________________ Zip Code__________ Insurer NCCI Number________________________________ Date of Report Quarter Ending Date Dollar Amount Submitted ______________________________________________ CERTIFYING OFFICIAL (Type Name) ______________________________________________ CERTIFYING OFFICIAL (Signature) ______________________________________________ TITLE __________________________ TELEPHONE NUMBER Mail Form and Check to: D.C. Department of Employment Services Office of the Chief Financial Officer 4058 Minnesota Avenue, NE - 5th Floor, Suite 5700 Washington, D.C. 20019 (Telephone: 202-671-1400) (1) (2) Submit a Copy of the Form to: D.C. Department of Employment Services Office of Workers' Compensation 4058 Minnesota Avenue, NE, Insurance Unit Washington, D.C. 20019 (FAX: 202-671-1929) ___________________ DATE Checks are payable to the D.C. Treasurer. This form may be reproduced or downloaded from the DOES website. The website address is www.does.dc.gov . American LegalNet, Inc. www.FormsWorkFlow.com