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Administration Fund Quarterly Assessment Instructions and Report Forms

 Quarterly Assessment Statement Submission Instructions
Quarterly assessment reports are due no later than 30 days after the end of the calendar quarter being reported.  
Blank “Quarterly Assessment Statement” forms are available at our website.  

Enter the name of the insurance company, the group name (if applicable), and the National Association of Insurance Commissioners (NAIC) codes for both entities.  
Line 1:  Total estimated direct premiums written. Identify the estimated direct written premiums for the period that you are currently reporting on Line 1.  
Line 2:  Assessment due. Multiply the direct written premiums (identified on Line 1) by the current assessment rate. Identify the result on Line 2.  
Line 3:  Prior quarter (over) & under payments. If applicable, identify on Line 3 an assessment amount that has been overpaid (as a credit) or was underpaid in the previous quarter.  
Line 4:  Balance Remitted. Add Line 2 and Line 3. If the amount is positive, identify this number on Line 4, and remit this amount along with your completed Quarterly Assessment Statement.  
Line 5:  Credit to be subtracted from next payment. Add Line 2 and Line 3. If the amount is negative, identify this number on Line 5. The next time your company’s Quarterly Assessment Statement is prepared, this amount will be entered on Line 3 to reflect the credit balance that currently exists.  
Should you have any questions, please contact Tami Furry at (802) 828-4117 or by email