Workers’ Compensation Security Fund 2003 Assessment Refund Application Form

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Department of Insurance

2003 Assessed Carrier Information

Please complete the questions in this section based on the carrier information as it was assessed in 2003.

2003 Assessed Carrier Company Name

2003 Assessed Carrier NAIC #

2003 Assessed Carrier Company FEIN #

Carrier’s Payment Amount for 2003 WCSF Assessment

Enter the code from the image