KANSAS DEPARTMENT OF LABOR www.dol.ks.gov K-WC 20 (Rev. 3-12) BANK FACT SHEET Date: Name of requesting self-insured company(ies): Name of parent bank: (If parental relationship exists, PROVIDE ULTIMATE PARENT DATA ON THIS FACT SHEET AS WELL AS ULTIMATE PARENT FINANCIALS.) Bank name: Street: City: Contact name: Phone number: Financial summary as of: Equity: Deposits: Loans/Discounts: Cash and due from bank: Securities: Total Assets: State: ZIP: Operating Ratios: ROA: ROE: Loan loss provision/Average loans: Net losses/Average loans: Loan loss reserve/Year-end loans: Loan loss reserve/Non-performing assets: Ratings: Thompson Bank Watch: Standard & Poors: Moody's: Sheshunoff: Capital Adequacy: Capital to weighted risk assets: Percent of core capital (Tier 1): Attach a copy of the annual report or call report. Authorized signature: Type name and title: DIVISION OF WORKERS COMPENSATION 401 SW Topeka Blvd., Suite 2, Topeka, KS 66603-3105 · Phone (785) 296-3606 · wcselfinsurance@dol.ks.gov American LegalNet, Inc. www.FormsWorkFlow.com