The verified statement, which shall be mailed to the employer by the Workers' Compensation Appeals Board simultaneously with the issuance of Findings of Fact, Findings and Order or Findings and Award, shall be found on the reverse side of the Direction to File Verified Statement and shall contain the following information:
(a) That the employer must complete the verified statement and submit the requested information to the Division.
(b) The number of employees in the employer's employ on the date of injury.
(c) A certification under penalty of perjury by the employer that such number is true and correct.
(d) The employer's signature, address and the date and place of execution thereof.