Surcharge Form {WC113}

WC113 - SURCHARGE FORM. This form is used by employers or insurance carriers in Colorado to report and pay a surcharge on workers' compensation premiums. This form is specifically for the period beginning July 1, 2024, and ending December 31, 2024. It calculates the surcharge based on the net premiums of workers' compensation insurance policies. The surcharge is applied to policies with deductibles less than $18,500 and those with deductibles greater than $18,500, using a $18,500 deductible basis for reporting purposes. The form includes a breakdown of various premiums and canceled premiums, and the total surcharge rate of 1.43% is then applied to the net premiums subject to surcharge. The surcharge is divided into three separate funds: the Major Medical and Subsequent Injury Funds, the Cash Fund, and the Premium Cost Containment Fund. The form must be signed under penalty of perjury by a President, Chief Officer, or Secretary of the company, and notarized. It also requires the FEIN (Federal Employer Identification Number), contact details for the person responsible, and notary information. www.FormsWorkflow.com