Workers Compensation Payroll And Assessment Quarterly Report Normal Plan {937}

Department of Consumer and Business Services Central Services Division P.O. Box 14610 Salem, OR 97309-0445 503-947-7941 Workers' Compensation Payroll and Assessment Quarterly Report Normal Plan Self-insured employer Name: Address: Gross payroll (to nearest dollar) 4-digit insurer no.: BIN: For quarter ending: Payroll description Base rate $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ TOTAL $ Employer's premium Class TOTAL $ Page 1 (continued on Page 2) 440-937 (5/16/DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkFlow.com Page 2 Self-insured employer name Total employer's premium (from Pg.1) $ Experience rating modification X Modified premium =$ Premium discount percentage 0% of the first $2,500 9.1% of the next 11.3% of the next 12.3% of all over $47,500 $387,500 $437,500 - Aircraft seat surcharge - See instructions Maximum of 10 seats per aircraft = seats X $ 25 Subtotal premium Subtract premium discount Net premium % = $ < $ $ $ $ $ > Subtotal assessment payable net premium X WCD assessment rate* *Assessment rates are established by OAR 440-045 and are published annually under separate bulletin. Debit balance forward per DCBS Apply previous credit balance: Credit balance per DCBS Subtract credit amount to be applied New credit balance $ <$ $ > . . . Subtract . . <$ > Total payment due $ This report is due not later than the last calendar day of the month following quarter end date. The director may assess a civil penalty for late reports or late payments. List each legal entity for which payroll is being reported 1 2 3 4 5 6 7 8 9 10 If additional lines are needed, list entities on a separate sheet of paper and attach. The undersigned hereby certifies that the figures appearing in the column of this report headed "Gross payroll" are a true and complete statement of the earnings of all your Oregon employees for the period stated. Signature Name (print or type) Email address Return with payment to: Department of Consumer & Business Services, Central Services Division 350 Winter St. NE P.O. Box 14610 Salem, OR 97309-0445 440-937 (5/16/DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkFlow.com BIN Date Title (print or type) Phone number DCBS use only: Fax number / Premium discount formula On premium of $ Portion above $437,500 Next $387,500 Next $47,500 First $2,500 12.3% 11.3% 9.1% 0.0% $ $ $ $ Discount $ $ $ Discount - $ - American LegalNet, Inc. www.FormsWorkFlow.com