Vermont Department of Labor Insurer's Reconciliation Statement 2016 NAIC Company Code: NAIC Group Code: Workers' Compensation Assessment Fund DUE: March 15, 2017 Calendar Year: Insurer Name: Group Name: 1. Direct Premiums Written Enter the amount of direct premiums written during the period January 1, 2016 through December 31, 2016 This amount should equal what is reported to the Vermont Department of Financial Regulation formerly known as 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 from January 1, 2016 to December 31, 2016 is 1.45% Multiply the amount on line 1 that was written between January 1, 2016 and December 31, 2016 by .0145 The total annual assessment due is: 2. 3. Quarterly Assessments Previously Submitted Enter the quarterly assessments due by quarter throughout calendar year 2016. Amount carried forward from 2015 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter TOTAL AMOUNT DUE January 1, 2016 ­ March 31, 2016 April 1, 2016 ­ June 30, 2016 July 1, 2016 ­ September 30, 2016 October 1, 2016 ­ December 31, 2016 3. 4. 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. Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com 5. Credit to be applied to next quarterly submission or amount to be refunded If line 3 is less than zero, this amount will carry forward and be credited toward the next quarterly assessment due. Alternately, this amount may be refunded if requested and the company is no longer writing workers' compensation in Vermont. CREDIT 5. 6. Certification I certify that the information identified above, and submitted, is true and accurate. (Signature) Name: Title: Group Address: (Date) Telephone: Email: Company Address: Include a copy of "Exhibit of Premiums and Losses (Statutory Page 14 Data)" with your submission Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com