Aggregate Annual Reporting Form - Reporting Period 7-01 To 6-30 {13A}

DOL FORM 13-A (Rev. 8/16) Reporter's Fed. Id No. Fiscal Year Department of Labor Workers' Compensation Division PO Box 488 Montpelier, VT 05601-0488 www.labor.vermont.gov AGGREGATE Annual Reporting Form ­ Reporting Period 7/01 ­ 6/30 Carrier: NAIC#_ ________________________________________ for Carrier: _ __________________________________________________ Third Party Administrator: Self-Insured: NAME: ADDRESS: CONTACT PERSON: CONTACT PHONE NUMBER: Benefit or Expense Paid Out E-MAIL: Total # Claims in which Benefit/Expense was Paid Total Amount Paid (all claims) Average benefit/cost per claim 1 2 3 4 5 6 7 8 9 10 11 Temporary Total Disability - Form 32 Temporary Partial Disability ­ Form 32 Permanent Partial Impairment ­ Form 22 Permanent Total Impairment ­ Form 22 Medical Vocational Rehabilitation Fatality (Spouse/dependent) ­ Form 23 Funeral Lump Sum Payments (Form 22 or 16) * Legal Expenses (Defense) TOTAL All Benefits/Expenses Paid $ $ $ $ $ $ $ $ $ $ $ Total Number $ $ $ $ $ $ $ $ $ $ $ 12 13 14 15 First Reports of Injury, Form 1 Fatalities Medical Only Claims Attach a list of all employers this report reflects. INSTRUCTIONS: 1. 2. 3. 4. COMPLETE each blank. Use N/A if appropriate. Provide information for FISCAL YEAR (7/1 ­ 6/30) ONLY. Do NOT duplicate report. If TPA is used, employer/carrier/TPA should agree upon annual reporter. *Attach itemization of lump sums of Form 16 and 22 if known. American LegalNet, Inc. www.FormsWorkFlow.com