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Fill and Sign the Full Text of Ampquotmissouri Department of Labor and Industrial Form

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MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONSDIVISION OF WORKERS' COMPENSATION SECOND INJURY FUND SURCHARGE Insurance Company Name, Address and NAIC Number 1 . 1. New or Renewal Premiums for Policies with 2001 Inception Dates: $ 1a. a. 2001 Surcharge Assessment @ 2.5%: (1x2.5%) $ 2. 2. New or Renewal Premiums for Policies with 2000 Inception Dates: $ 2b. b. 2000 Surcharge Assessment @ 3%: (2x3%) $ 3. 3. Additional Premiums Collected or Returned for Policies with 1999 Inception Dates: $ 3c. c. 1999 Surcharge Assessment @ 3%: (3x3%) $ 4. Late Payment Penalty and Interest for Payments Occurring More Than 30 Days After the End of the Quarter: (la+2b+3c) 4. $ 4d. d. Late Payment Penalty @ .5%. Interest @ 1.5% per month. (4 x2%) $ TOTAL MISSOURI SECOND INJURY FUND SURCHARGE DUE: (Add 1a, 2b, 3c and 4d to arrive at the combined total) $ Mail one copy and your check for the surcharge to: Missouri Department of Revenue P.O. Box 898 Jefferson City, MO 65105-0898 (Mail this copy even if no money is due at this time.) Mail one copy to: Missouri Division of Workers' Compensation Attn: Second Injury Fund P.O. Box 58 Jefferson City, MO 65102-0058 (Mail this copy even if no money is due at this time.) Keep one copy for your records. These forms are due 30 days after the end of each Quarter, i.e., not later than April 30, July 30, October 30 and January 30. WC- 1 15 (O I -0 1) Al FOR QUARTER ENDING

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