4th Quarter 2007 MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DIVISION OF WORKERS' COMPENSATION October 1, 2007 - December 31, 2007 (Delinquent and Penalty due if received after January 30, 2008) SECOND INJURY FUND SURCHARGE FOURTH QUARTER Commercial Insurance Carriers (Please submit a separate form for each company.) Company Name and Address: NAIC # Parent Company or Group Name and Address: FEIN # NAIC # FEIN # NAIC # FEIN # If there has been a name or ownership change in the past 24 months please indicate previous name(s) or owner(s): Date this form will be sent: THE DATE ABOVE MUST BE ENTERED IN ORDER FOR AMOUNTS TO CALCULATE CORRECTLY. 1. New or renewed gross premiums for policies with 2007 inception dates Returned or refunded premiums for policies with 2007 inception dates Net Premium a. Multiply by 2007 Surcharge Assessment (3.0%) = = New, renewal or additional gross premiums for policies with 2006 inception dates - Returned or refunded premiums for policies with 2006 inception dates Net Premium b. Multiply by 2006 Surcharge Assessment (3.0%) = = Additional gross premiums collected for policies with 2005 and prior inception dates Returned or refunded premiums for policies with 2005 and prior inception dates Net Premium c. Multiply by 2005 Surcharge Assessment (3.5%) 2. Total lines 1a, b, & c = = = $0.00 Total Missouri Second Injury Fund Surcharge Due: 3. If received by the Division after January 30, 2008, the payment is delinquent and a late payment is owed. Additionally, interest is due for each month or fraction thereof delinquent. Continue completing this form. a. Enter amount shown in Item 2 (Total lines a, b, & c) b. Late penalty, which is the Surcharge Assessment Subtotal x 0.5% + c. Interest, which is the Surcharge Assessment Subtotal x 1.5% x total number of months delinquent (any fraction of a month delinquent is considered a full month delinquent) + 4. Add lines 3a, b, & c = Total Missouri Second Injury Fund Surcharge w/ Penalty & Interest Due: Name of person completing form E-mail Address Phone Number Date I hereby certify that this application contains no willful misrepresentation or falsifications and that the information provided is true and complete to the best of my knowledge and belief. Signature - Pres./Exec. Officer Printed Name Title Date Mail one copy of this form and a check made payable to: Missouri Division of Workers' Compensation, Attn: Second Injury Fund, P.O. Box 58, Jefferson City, MO 65102-0058 (Mail this copy even if no money is due at this time.) Keep one copy for records. WC-115C (02-07) AI American LegalNet, Inc. www.FormsWorkflow.com