EMPLOYER'S REPORT TO COMMISSIONER OF FINANCE
GIF Form No. ta (Rev.) Policy NO... . cee ee ee ee ete (7-30-80) . Bill Nos........... Fe Ok OS ReSIES BS ES Ledger Page ; Refund Voucher No.................. NG@scccr cs we enero EMPLOYER'S REPORT TO COMMISSIONER OF FINANCE for purposes of determining amount of premium for Workmen's Compensation Insurance, required under Title 24, Chapter 11, Section 275, of the Virgin Islands Code Name of Business Establishment and/or Nature of EHR iccccmnememee ow une wmneneeeT ROGGS is cece came Re uM A ws ee Business ...... ee (If eeverdl, submit separate report for each business) Location of Employment........... AOWEN 8 OA VA SERENA HeewA Eee or » te SECTOR CA LNA S REESE Telephone No................ CLASSIFICATION OF EMPLOYEES i th te weRGes salaries and Number of (use description of occupation &s classified ; wages paid from........... …
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GIF Form No. ta (Rev.) Policy NO... . cee ee ee ee ete (7-30-80) . Bill Nos........... Fe Ok OS ReSIES BS ES Ledger Page ; Refund Voucher No.................. NG@scccr cs we enero EMPLOYER'S REPORT TO COMMISSIONER OF FINANCE for purposes of determining amount of premium for Workmen's Compensation Insurance, required under Title 24, Chapter 11, Section 275, of the Virgin Islands Code Name of Business Establishment and/or Nature of EHR iccccmnememee ow une wmneneeeT ROGGS is cece came Re uM A ws ee Business ...... ee (If eeverdl, submit separate report for each business) Location of Employment........... AOWEN 8 OA VA SERENA HeewA Eee or » te SECTOR CA LNA S REESE Telephone No................ CLASSIFICATION OF EMPLOYEES i th te weRGes salaries and Number of (use description of occupation &s classified ; wages paid from........... ; Employees in Handbook on Workmen's Compensation Insurance) RD ccinvecereranene e ‘ CODE PREMIUM RATE | PREMIUM AMOUNT | || | | | | | | | | | | || | | } | | | | L | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | || | | | | | | } | | INDICATE IF THE peyoven IS IPSLUDED IN TOTALS (if Business Discontinued indicate by THIS REPORT YES|_|..... NOL_|]...... . writing “Final Report’) . -$ | | * State “ESTIMATED” § “ACTUAL” BILLING EXPERIENCE RATING PLAN Estimated Premiums paid for Premiums payments received over the past 3 calendar years CY $ Claim P ad Pied he o $ lend Actual Premium for CY. $: im Payments made ovar the past 3 calendar years Additional Sania Gk Ciel to ; dus tor CY $ Ratio of Chargeable Claim Cost to Premium Payments Experience Rating Credit or ($ + § = Incresse CY. $ CREDIT ON PREMIUMS FOR SUBSEQUENT YEAR Total Premium due for CY... . 5 INCREASE 1N PREMIUM FOR SEBSEQUENT YEAR Signature Title : Print Name Data NOTE: Prepare this report in Duplicate. Submit original and one copy to the Government Insurance Fund, Depart ment of Finance e