Assessment Report 2012 {WCC 10}

ASSESSMENT REPORT 2013 FOR INSURANCE COMPANIES, SELF-INSURERS & GROUP FUNDS STATE OF ALABAMA DEPARTMENT OF LABOR WORKERS' COMPENSATION DIVISION 649 Monroe Street Montgomery, Alabama 36131 Telephone: (334) 242-2868 Toll Free 1-800-528-5166 COMPANY NAME: CONTACT PERSON: MAILING ADDRESS: PHYSICAL ADDRESS: CITY ST ZIP: EMAIL: NCCI#: FEIN#: SI#: GSI#: TELEPHONE#: SUBSIDIARIES OF SELF INSURED COMPANIES: PLEASE MAKE ALL CHANGES TO ABOVE INFORMATION IF NECESSARY and INCLUDE YOUR EMAIL & TELEPHONE In accordance with the Alabama Workers' Compensation Law, Title 25, Code of Alabama, 1975, as last amended, this report is to be filed with the State of Alabama on or before the first day of March each year. The total expenses reported will be used in the calculation of your 2013 assessment. DO NOT include negative amounts DO NOT DEDUCT SUBROGATION OR REINSURANCE/EXCESS RECOVERABLES Compensation Paid: Medical Paid: Attorney Fees Paid: Administrative Expenses Paid: Court Settlements: $______________________________ $______________________________ $______________________________ $______________________________ $______________________________ TOTAL LOSSES: $_________________________ CERTIFICATION UNDER PENALTY OF PERJURY, I, ___________________________________________________, being duly sworn, dispose, affirm, and verify that PRINT YOUR NAME the foregoing is a true and correct report of workers' compensation payments made in accordance with the Alabama Workers' Compensation Law, as last amended. I further verify and affirm that this report constitutes a true and correct report of payments made by all operations with the state. I understand that the monetary figures and sums certain contained therein will be used to compute the workers' compensation assessment due and payable to the Alabama Workers' Compensation Administrative Trust Fund. I further verify and affirm that I am a duly appointed official of Company: _______________________________ in the capacity of _____________________________ and that I am duly qualified and authorized to sign this report. Printed Name Corporate Title ____________________________________________________ Signature Sworn to and subscribed before me this _______ day of _______________, 2013 _____. WCC Form 10 rev. 1/ 2013 ____________________________________________________ Notary Public American LegalNet, Inc. www.FormsWorkFlow.com