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Insurers Reconciliation Statement 2008 Form. This is a Vermont form and can be use in Workers Compensation.
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Tags: Insurers Reconciliation Statement 2008, Vermont Workers Compensation,
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
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