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Aggregate Annual Reporting Form - Reporting Period 7-01 To 6-30 13A - Vermont
|Aggregate Annual Reporting Form - Reporting Period 7-01 To 6-30 Form. This is a Vermont form and can be used in Workers Compensation .||
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Form 13-A Instruction Sheet State of Vermont Department of Labor & Industry National Life Building, Drawer 20 Montpelier, VT 05620-3401 Form 13-A Instruction Sheet Form 13-A is an AGGREGATE annual report form. This report requires only ONE form per reporter rather than one form for every claim. Each reporter (insurance carrier, third-party administrator (TPA), or self-insured) should review and be aware of the following: General Annual Reporting Instructions 1. Use ONE Form 13-A. 2. Do NOT use a separate Form 13-A for separate claims. 3. The traditional Form 13 is no longer necessary. You may provide a Form 13 from each of your claims, if you have them available and you wish to provide them. 4. It is no longer necessary to file a Form 13 upon closing a file. 5. Do NOT duplicate report. Only one Form 13-A is required per reporter (carrier, TPA or self-insured). For example, if a self-insured uses a TPA, only one should report, for the self-insured. (usually the TPA) Both should not report ffor the Self-insured as this would create duplicate reporting of information. Instructions for Filling Out Your Form 13-A 1. Complete the form in its entirety. 2. Provide information for the fiscal year only, 7/1-6/30. Do not include costs or expenses for the full life of any claim. 3. Provide AGGREGATE information as requested. For example, at box 1 enter the total number of all claims over the entire fiscal year in which you made any a TTD payment. 4. ATTACH to your Form 13-A a list of all employers you are reporting for. 5. Optional items. Provide optional details requested only if available. For further questions please call Sue Millen at the Workers Compensation Division at (802) 828-5076 or e-mail her at email@example.com. <<<<<<<<<********>>>>>>>>>>>>> 2 DOL FORM 13-A (Rev. 7/03) Reporters Fed. Id No. Fiscal Year State of Vermont Department of Labor & Industry Workers Compensation Division www.state.vt.us/labind/wcindex.htm AGGREGATE Annual Reporting Form Reporting Period 7/01 6/30 Carrier: NAIC#_ ________________________________________ Third Party Administrator: for Carrier:_ __________________________________________________ Self-Insured: NAME: ADDRESS: CONTACT PERSON: CONTACT PHONE NUMBER: E-MAIL: Benefit or Expense Paid Out Total # Claims in Total Amount Paid Average which Benefit/Expense (all claims) benefit/cost per was Paid claim 1 Temporary Total Disability - Form 21 $ $ 2 Temporary Partial Disability Form 24 $ $ 3 Permanent Partial Impairment Form 22 $ $ 4 Permanent Total Impairment Form 22 $ $ 5 Medical $ $ 6 Vocational Rehabilitation $ $ 7 Fatality (Spouse/dependent) Form 23 $ $ 8 Funeral $ $ 9 Lump Sum Payments (Form 22, 14 or 15)* $ $ 10 Legal Expenses (Defense) $ $ 11 TOTAL All Benefits/Expenses Paid $ $ Total Number 12 First Reports of Injury, Form 1 13 Fatalities 14 Medical Only Claims 15 Attach a list of all employers this report reflects. INSTRUCTIONS: 1. COMPLETE each blank. Use N/A if appropriate. 2. Provide information for FISCAL YEAR (7/1 6/30) ONLY. 3. Do NOT duplicate report. If TPA is used, employer/carrier/TPA should agree upon annual reporter. 4. *Attach itemization of lump sums of Form 14, 15 and 22 if known.