Form 26A-11/5/2012 COMMONWEALTH OF VIRGINIA 001002003004005003006007bt002n013005f006r016017002fbt002nn017006006017002fb RICHMOND, VIRGINIA 232 ATTN: FINANCIAL SERVICES Annual Report of Premiums, Assessments, Etc., Received by Insurance Carriers IMPORTANT: As provided by Section 65.2-1001 of the Virginia Workers222 Compensation Act, every insurance carrier on account of business done in Virginia shall, for the twelve months ending December 31st of each year, make a return verified by the affidavits of its President and Secretary, or other chief officers or agents, to the Workers222 Compensation Commission stating the amount of premiums and credits during the period covered by such return. The return must be filed with the Commission on or before January 31st and the carrier shall at the same time pay into the State Treasury, a tax (see attached cover letter for current tax rate) on each one hundred dollars of such premiums ascertained less canceled or returned premiums actually refunded during the year on such insurance and premiums on reinsurance assumed. See instructions on reverse side. Year Ended December 31, 001002003004005006007004b007007tn013f005rn016002007017004020003rn021007004b007(Location of Head Office) (NAIC NO.) Gross premiums, assessments, etc., on Workers222 Compensation Insurance, Excluding Reinsurance Assumed (1)$Less gross premiums refunded205205205205205205205205205205205205205205205205 ( 2) $ NET PREMIUMS205205205205205205205205205205205205205205205 205205 (3)$TAX ON NET PREMIUMS, (4) $ at (5) Percent205205205205.(6) $ (Net Premiums) Tax Rate (TAX DUE) (Signature of President or Other Chief Officer or Agent) (Date) (Signature of Secretary or Other Chief Officer or Agent) (Date) This day (Name of President or Other Chief Officer or Agent) (Title of Officer) (Name of Secretary or Other Chief Officer or Agent) (Title of Officer) of (Name of Insurance Company) (Fed. Tax ID#) personally appeared before me, acknowledged their signatures, and made oath that the foregoing report is correct. Given under my hand and notarial seal this day of , in the city/county of . SEAL (Notary Public) My commission expires . American LegalNet, Inc. www.FormsWorkFlow.com FORM 26A INSTRUCTIONS Type or print, on the form, all required information. Year Ended December 31, - enter calendar year being reported. Report of... - enter name of company, address of main office and NAIC No. Complete the numbered spaces with the following information: (1) Report gross amount of all assessments, etc., received or obligations taken therefor, without any deduction for losses, dividends, commissions or other expenses, on account of workers222 compensation business in the state of Virginia. (2) Amount of gross premiums returned. (3) Subtract (2) from (1) and enter on this line. (If the difference is greater than $0.00, continue to (4). If not, see instructions under Negative Net Premiums. (4) Enter the amount from (3). (5) Total tax rate from cover letter. (6) Apply tax rate to net premiums. (Multiply (4) and (5).) This is your tax due. Enclose, with your report, a check for the total amount due. Negative Net Premiums If the amount on line (3) is negative, you may be due a refund. Do not complete lines (4), (5) or (6). Attach an additional report giving the year that all reported returned premiums were originally reported to the Commission. Example: In 1994 XYZ Insurance Company included in their report, premiums from 123 Company in the amount of $200,000. In 1996, XYZ222s net premiums reported were negative, which included returned premiums for 123 Company in the amount of $50,000. The additional report required for 1996 would include $50,000 for 1994. If negative net premiums are reported, be sure that the company222s Fed. Tax ID# is entered on the form. Form must be signed by two chief officers of the company and notarized. The deadline for filing and payment of taxes is January 31st. Please enter the name and telephone number of the person to contact if we have any questions regarding this report. Please print. Name of Contact Telephone Number American LegalNet, Inc. www.FormsWorkFlow.com