(a) Whenever a dividend is paid on a workers' compensation policy, a written form captioned "Policyholder Dividend Statement" shall accompany the dividend paid or, where no dividend is paid, shall be provided in place of a dividend. (1) The Policyholder Dividend Statement shall identify the policyholder and the insurer, the policy to which the statement applies, and the term of said policy. (2) The Policyholder Dividend Statement shall present the calculation of the dividend result, and shall provide