Vermont Department of Labor Workers’ Compensation Assessment Fund Insurer’s Reconciliation Statement Calendar Year: 2008 DUE: Group Name: NAIC Group Code: Company Name: March 15, 2009 NAIC Company Code: Did the company name change during calendar year 2008? Yes No New Company Name: Yes No New Group Number: Did the group number change? During calendar year 2008 was this company involved in a merger? Yes No If yes, what other NAIC codes were involved? 1. Direct Premiums Written Enter the amount of direct premiums written During the period January 1, 2008 through December 31, 2008 This amount should equal what is reported to the Vermont Department of Banking, Insurance, Securities and Health Care Administration (BISHCA), on the company’s annual statement. [Exhibit of Premiums and Losses (Statutory Page 14 Data), Line 16, Column 1] 1. 2. Annual Assessment Due The Vermont General Assembly establishes the assessment rate annually. The assessment rate form January 1, 2008 to June 30, 2008 is .42% The assessment rate from July 1, 2008 to December 31, 2008 is .81% Multiply the amount on line 1 that was written between January 1, 2008 and June 30, 2008 by .0042. Multiply the amount on line 1 that was written between July 1, 2008 and December 31, 2008 by .0081. This is the total annual assessment due. 2. 3. Quarterly Assessments Previously Submitted Enter the quarterly assessments due by quarter throughout calendar year 2008. Amount carried forward from 2007 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter January 1, 2008 – March 31, 2008 April 1, 2008 – June 30, 2008 July 1, 2008 – September 30, 2008 October 1, 2008 – December 31, 2008 TOTAL AMOUNT DUE 4. 3. Balance Due Subtract line 3 from line 2. If the amount is greater than 0, this is the remaining assessment amount due. If the amount is less than 0, enter the amount on Line 5. Make Checks Payable to: Vermont Department of Labor Forward check, and this form, to: Workers’ Compensation Admin Fund PO Box 488 Montpelier, VT 05601-0488 AMOUNT DUE 4. 5. Credit to be applied to next quarterly submission or Amount to be refunded If line 5 is less than zero, this amount will carry-forward and be credit towards the next quarterly assessment due. Alternatively, this amount may be refunded if requested. CREDIT 5. 6. Certification I certify that the information identified above, and submitted, is true and accurate. (Signature) (Date) Name: Telephone: Title: Email: Group Address: Company Address: Include a copy of “Exhibit of Premiums and Losses (Statutory Page 14 Data)” with your submission American LegalNet, Inc. www.FormsWorkflow.com