Claudia Clark Vt Dept. NAIC Code Federal Tax ID Number 1. The foregoing is an accurate estimate of direct written premiums for the period indicated.
All information provided is complete and correct.
Please make copies of this form, or you may create your own computer form using the same format and including all the information requested on this form. Enter your Group Name, Insurer, Federal Tax ID, and NAIC Codes. Total estimated direct premium. Enter the estimated direct premium for the period that you are currently reporting only. Add line 2 and line 3 together.