South Carolina Workers' Compensation Commission 1333 Main Street, Suite 500 P.O. BOX 1715 Columbia, SC 29202-1715 (803) 737-5706 Page One of Two FUND QUARTERLY FINANCIAL REPORT FUND NAME: ASSETS: 1. Cash 2. Marketable Securities 3. Premiums Receivable 4. Receivable from Excess Insurance 5. Accounts Receivable 6. Other Assets 7. Total Assets LIABILITIES: 8. Claims Reserves 9. Accounts Payable 10. Other Liabilities 11. Total Liabilities FUND BALANCE: Line 7 minus Line 11 REVENUES: 12. Premium 13. Investment Income 14. Other Income 15. Total Revenues OPERATING EXPENSES: 16. Claims Expense 17. Excess Insurance Premiums 18. Service Fees 19. Administrative Costs 20. Legal Fees 21. Other Expenses 22. Total Expenses OPERATIONS SURPLUS (DEFICIT): Line 15 minus Line 22 QUARTER ENDING: (m/d/yyyy) QUARTER TOTAL YTD. $ $ $ $ $ $ $0.00 $ $ $ $0.00 $0.00 $ $ $ $0.00 $ $ $ $ $ $ $0.00 $0.00 $ $ $ $0.00 $ $ $ $ $ $ $0.00 $0.00 WCC Form # 11 Rev. Date 3/96 11 FUND QUARTERLY FINANCIAL REPORT American LegalNet, Inc. www.FormsWorkFlow.com South Carolina Workers' Compensation Commission 1333 Main Street, Suite 500 P.O. BOX 1715 Columbia, SC 29202-1715 (803) 737-5706 Page Two of Two INVESTMENT SCHEDULE TYPE OF INVESTMENT IDENTIFICATION NUMBER PURCHASE DATE (m/d/yyyy) RATE AMOUNT TERM PLEDGED SECURITY $ $ $ $ $ $ $ $ $ $ $ $ $ $ Name (Fund Director or Chairman) Title Date WCC Form # 11 Rev. Date 3/96 11 FUND QUARTERLY FINANCIAL REPORT American LegalNet, Inc. www.FormsWorkFlow.com