State of Vermont
Workers' Compensation Administration Fund
QUARTERLY ASSESSMENT STATEMENT
FOR QUARTER ENDING
Insurer: Group: Federal Tax ID Number (Insurer):
NAIC Company Code: NAIC Group Code:
1. 2. 3. 4. 5.
Total estimated direct premiums written for the quarter being reported: Assessment due (Line 1 X .0081): Prior quarter (over) & under payments (explain on reverse, if necessary): Balance Remitted (Line 2 minus Line 3): - or Credit to be subtracted from next payment:
$ $ $ $ $
Make checks payable to:
Vermont Department of Labor Workers' Compensation Administration Fund 5 Green Mountain Drive, PO Box 488 Montpelier, VT 05601-0488
The foregoing is an accurate estimate of direct written premiums for the period indicated.
(Signature)
(Date)
Name: Title: Email:
Telephone: Fax:
Address:
WCAF Form 2, 01/05
.4% Assessment