Semi Annual Premium Tax Computation Form For Idaho Self Insured Employer {IC-4010A}

SEMI-ANNUAL PREMIUM TAX COMPUTATION FORM FOR IDAHO SELF-INSURED EMPLOYER SELF-INSURED'S NAME: FEIN : PREMIUM TAX COMPUTATION FOR THE PERIOD ENDING: 1 Gross Wages 2 3 4 5 6 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Enter as a Negative Less: Overtime Premium in excess of regular wages - Enter as a Negative Less: Certain Executive Officer Wages Over Weekly maximum - Enter as a Negative Less: Unworked Severance Pay - Enter as a Negative Less: Other "as defined by NCCI Rules" - Enter as a Negative Total Deductions 7 Net Direct Wages Risk Code Description Gross Wages by Job Class $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8 Subtotals: 0 $0.00 9 E-MOD (Enter your E-Mod rate or a 1) 10 TOTAL MODIFIED PREMIUM LAST SIX MONTHS OF WAGES TIMES 2 FOR ANNUALIZATION ANNUALIZED WAGES PREMIUM DISCOUNT Applied Discount Basis Percentage First $ 10,000 of Premium 0.00% Next $ 190,000 of Premium 9.10% Next $1,550,000 of Premium 11.30% Over $1,750,000 of Premium 12.30% Total Premium must equal Annualized Wages: # EE Less Total Deductions $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Net Direct Wages $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Risk Rate Premiums Paid $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1.00 $0.00 $0.00 2 $0.00 Total Premium Computed Discount $10,000.00 $10,000.00 $0.00 $0.00 $0.00 $0.00 $0.00 50% $0.00 11 TOTAL WORKERS' COMPENSATION PREMIUM 12 LESS: PREMIUM DISCOUNT 13 NET PREMIUM 14 TAX RATE 15 PREMIUM TAX DUE $0.00 $0.00 $0.00 2.00% $0.00 American LegalNet, Inc. www.FormsWorkFlow.com IC-4010A REV 5/14/15