December 13, 2004



Date

Dear President/Owner:

RE: Florida Workers Compensation Law

Required Quarterly Payroll Report

Pursuant to the Florida Workers’ Compensation Law (F.S. 440.381) each employer is required to submit to their insurance carrier at the end of each quarter a copy of the payroll report provided to the Division of Unemployment Compensation. This report is the Florida Unemployment Quarterly Tax and Wage Report (Form LES #UCT-6) with employee detail.

Effective October 1, 2003, F.S. 440.381 requires Partner’s, Sole Proprietor’s or Corporate Officers Statement and a Statement of the individual providing the audit information (if other than the Partner, Sole Proprietor, or Corporate Officer) to be completed, signed and attach a copy of proof of identification. (to the enclosed OIR-B1-1562 and or OIR-B1-1561 State of Florida forms.) Acceptable forms of identification are State issued Driver License or State issued identification card. To protect your privacy, please white out any personal information on the submitted copy. (address, DOB etc) These forms are to be completed and signed each quarter. Please note: a copy of proof of identification (copy of photo ID) will only be required once during the policy period of coverage unless changes occur.

Due to recent changes to the FL Workers Compensation Statue, FHM now requires the Sub-Contractor/Casual Labor form be completed, signed and returned with each quarterly self-audit report. Please see page 3.

To ensure the proper premium is collected, please complete the enclosed audit package in its entirety. If you fail to provide all the information requested, higher premiums may result. On the UCT-6, please indicate beside each employee’s name his or her proper Workers Compensation classification code. Please remember to include Section 125 wages on the Gross Payroll Summary in the spaces indicated. Please provide a copy of the IRS 941 form to receive proper tip credit if applicable. Your latest Workers Compensation premium invoice lists the correct employee classification codes for your policy.

Mail or Fax all wage records with supporting documents to:

FHM INSURANCE COMPANY

AUDIT DEPARTMENT

PO BOX 616648

ORLANDO FL 32861-6648

407-926-9419 Fax

Please contact the Audit Department, Extension 252 or 204, if you have any questions.

Sincerely,

Meredith Katic

Senior Payroll Auditor

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