MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS AFFIDAVIT OF ZERO REPORTING ­ COMMERCIAL INSURERS ONLY FOR CALENDAR YEAR Company Name, Address and NAIC #: 3315 West Truman Blvd. P.O. Box 58 Jefferson City, MO 65102-0058 www.labor.mo.gov/DWC Company Contact, Phone Number and E-mail Address: Name of President/Executive Officer Name of Person Completing Affidavit/Title Before me, the undersigned authority, personally appeared being duly sworn on oath stated that: I am the President/Executive Officer or the Person Completing the Affidavit (if different from the President/Executive Officer) respectively of the who, and I am of sound mind, capable of making this affidavit and (Name of Employer) acquainted with the facts herein stated. The company is reporting zero Second Injury Fund Surcharge due pursuant to Section 287.715, RSMo et seq. for the calendar year . This is based upon the fact that the company had no Missouri direct written workers' compensation premiums to date for the calendar year in question. If during the course of the calendar year the direct written workers' compensation premiums become something other than zero, the company will begin remitting the appropriate Second Injury Fund Surcharge forms and payments. Signature of President/Executive Officer Signature of Person Completing Affidavit Notary Public Embosser or State of Black Ink Rubber Stamp Seal Subscribed and Sworn Before Me, This Day Of Notary Public Signature Notary Public Name (Typed or Printed) Year My Commission Expires County (Or City of St. Louis) Use Rubber Stamp in Clear Area Below WC-240 (03-12) AI American LegalNet, Inc. www.FormsWorkFlow.com