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

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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



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