5 Green Mountain Drive, PO Box 488 Montpelier, VT 05601-0488 SELF-INSURER'S REPORT DUE MARCH 1st Calendar Year: Company: 1. Total Workers' Compensation Benefits paid for the reporting period: (a) (b) (c) (d) 2. Assessment due [line (d) x .01]: Indemnity: Medical: Other: Total: $ $ $ $ $ 3. Claims for which benefits were paid for this reporting period. (this may be included on a separate form provided that all the information requested is present): Name Date of Injury State File Number 4. Certification: I certify that the information identified above, and submitted, is true and accurate. Signature Name: Title: Group Address: Telephone: Email: Company Address: Date REVISED 7/2015 American LegalNet, Inc. www.FormsWorkFlow.com