(H /(//  (uG"  %   CBCOPY)) RS0PY(!  ? @VLBLBq+q+q+q0*     ! "!#$"%$&%'&( ~';'MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS''DIVISION OF WORKERS' COMPENSATION"'SECOND INJURY FUND SURCHARGE'FOR QUARTER ENDING5'Insurance Company Name, Address and NAIC NumberH '1. New or Renewal Premiums for Policies with 1999 Inception Dates: '$/ ' a. 1999 Surcharge Assessment @ 3%: (1xa) % 3'2. Additional Premiums Collected or Returned '-'for Policies with 1998 Inception Dates:'$0' b. 1998 Surcharge Assessment @3.0%: (2xb)%H'3. Late Payment Penalty for Payments Occurring More Than 30 Days )'After the End of the Quarter: (1+2)'$+' c. Late Payment Penalty @.5%: (3xc )K7'TOTAL MISSOURI SECOND INJURY FUND SURCHARGE DUE: % P9^(Add 1a, 2b and 3c to arrive at the combined total)8^Mail one copy and your check for the surcharge to:$^Missouri Department of Revenue^ P.O. Box 898$^Jefferson City, MO 65105-0898<^(Mail this copy even if no money is due at this time.)' ^Mail another copy to:0 ^Missouri Division of Workers' Compensation!^P.O. Box 58$"^Jefferson City, MO 65102-0058<#^(Mail this copy even if no money is due at this time.)$%^Keep one copy for your recordsA'^These forms are due 30 days after the end of each Quarter, H(^i.e., not later than April 30, July 30, October 30 and January 30.-