memo

' .. December 10, 2003 • STATE OF HAWAII INSURANCE DIVISION DEPARTMENT OF COMMERCE & CONSUMER AFFAIRS P. 0. BOX 3614 HONOLULU, HAWAl'I 96811-3614 335 MERCHANT STREET, 2ND FLOOR HONOLULU, HAWAl'I 96813 Memorandum 2003-8E TO: INSURERS AUTHORIZED TO WRITE WORKERS' COMPENSATION INSURANCE IN HAWAII SUBJECT: WORKERS' COMPENSATION SPECIAL COMPENSATION FUND Section 386-152, Hawaii Revised Statutes, requires a levy to finance the Special Compensation Fund when the cash balance of the fund falls below an amount deemed necessary to meet the Fund's current and projected obligations. The Director of Labor and Industrial Relations who administers the Special Compensation Fund advises that the fund balance was insufficient to meet the required level of funding as of December 31, 2003. The levy to be assessed insurers writing Workers' Compensation insurance shall be 4% of the 2003 gross premiums. In accordance with the above, you are to report on the enclosed Form 315, the gross premiums written from Workers' Compensation insurance issued during 2003 and show the amount of levy due and payable. Checks should be made payable to "DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS, STATE OF HAWAII." TO BE FILED ON OR BEFORE MARCH 15, 2004 FILING DATE MARCH 15, 2004 • STATE OF HAW All DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS INSURANCE DIVISION P. 0. Box 3614 Honolulu, ID 96811-3614 ATTN: SUSAN HANSEN 335 Merchant Street, 2°d Fir. Honolulu, ID 96813 ATTN: SUSAN HANSEN STATEMENT OF PREMIUMS DERIVED FROM WORKERS' COMPENSATION INSURANCE ISSUED DURING THE YEAR FOR WORKERS' COMPENSATION SPECIAL COMPENSATION FUND NAIC # _______ _ FOR THE YEAR ENDED DECEMBER 31, 2003 Round all amounts to nearest dollar 1. TOTAL GROSS PREMIUMS* SUBJECT TO SPECIAL LEVY .... lu, ID 96811-3614 ATTN: SUSAN HANSEN 335 Merchant Street, 2°d Fir. Honolulu, ID 96813 ATTN: SUSAN HANSEN STATEMENT OF PREMIUMS DERIVED FROM WORKERS' COMPENSATION INSURANCE ISSUED DURING THE YEAR FOR WORKERS' COMPENSATION SPECIAL COMPENSATION FUND NAIC # _______ _ FOR THE YEAR ENDED DECEMBER 31, 2003 Round all amounts to nearest dollar 1. TOTAL GROSS PREMIUMS* SUBJECT TO SPECIAL LEVY ..... $========== *Workers' Compensation gross premiums written from all risks resident, situated or located within Hawaii, includes all fees, charges, or other consideration charged for the insurance or for its procurement (Section 431: 10- 218, Hawaii Revised Statutes). 2. AMOUNT DUE AND PAY ABLE ON OR BEFORE MARCH 15 (Line 1 times assessment rate of 4% --- see attached Memorandum 2003-8E) .................................. $=========== (Payable to DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS, STATE OF HA WAii) County of ______________ _ } ss. _____________________________________ ,being duly sworn, deposed and says: That (they are) (he/she is) the of the Insurer whose name appears above and that this statement is to the best of (their) (his/her) knowledge, information and belief, true and complete return, made in good faith, for the period stated. Subscribed and sworn to before me this day of ___________ ___ _ Signature of Officer of Insurer Notary Public, State of ______________ _ My commission expires:--------------- Signature of Officer oflnsurer 315 (Rev. 10/03) WCF