Oregon > Workers Comp > Insurer And Self Insurer
Workers Compensation Payroll And Assessment Quarterly Report Normal Plan 937 - Oregon
| Workers Compensation Payroll And Assessment Quarterly Report Normal Plan Form. This is a Oregon form and can be used in Insurer And Self Insurer Workers Comp . |
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Department of Consumer and Business Services Fiscal and Business Services 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 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 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 0.00 0.00 0.00 0.00 Employer's premium - Class $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ TOTAL $ Page 1 - TOTAL $ (continued on Page 2) - 440-937 (5/12/DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkFlow.com Department of Consumer & Business Services Fiscal and Business Services P.O. Box 14610 Salem, Oregon 97309-0445 (503) 947-7941 Workers' Compensation Payroll & 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 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 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 0.00 0.00 0.00 0.00 Employer's premium - Class $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ PAGE SUBTOTAL $ TOTAL $ Page 1.1 440-937 (5/12/DCBS/WCD/WEB) - SUBTOTAL $ TOTAL $ - (continued on Page 2) American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com Department of Consumer & Business Services Fiscal and Business Services P.O. Box 14610 Salem, Oregon 97309-0445 (503) 947-7941 Workers' Compensation Payroll & 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 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 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 0.00 0.00 0.00 0.00 Employer's premium - Class $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ PAGE SUBTOTAL $ TOTAL $ Page 1.2 440-937 (5/12/DCBS/WCD/WEB) - SUBTOTAL $ TOTAL $ - (continued on Page 2) American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com Department of Consumer & Business Services Fiscal and Business Services P.O. Box 14610 Salem, Oregon 97309-0445 (503) 947-7941 Workers' Compensation Payroll & 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 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 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 0.00 0.00 0.00 0.00 Employer's premium - Class $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ PAGE SUBTOTAL $ TOTAL $ Page 1.3 440-937 (5/12/DCBS/WCD/WEB) - SUBTOTAL $ TOTAL $ - (continued on Page 2) American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com Department of Consumer & Business Services Fiscal and Business Services P.O. Box 14610 Salem, Oregon 97309-0445 (503) 947-7941 Workers' Compensation Payroll & 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 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 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 0.00 0.00 0.00 0.00 Employer's premium - Class $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ PAGE SUBTOTAL $ TOTAL $ Page 1.4 440-937 (5/12/DCBS/WCD/WEB) - SUBTOTAL $ TOTAL $ - (continued on Page 2) American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com Department of Consumer & Business Services Fiscal and Business Services P.O. Box 14610 Salem, Oregon 97309-0445 (503) 947-7941 Workers' Compensation Payroll & 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 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 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 0.00 0.00 0.00 0.00 Employer's premium - Class $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ PAGE SUBTOTAL $ TOTAL $ Page 1.5 440-937 (5/12/DCBS/WCD/WEB) - SUBTOTAL $ TOTAL $ - (continued on Page 2) American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com Page 2 Self-insured employer name Total employer's premium (from Pg.1) $ - Premium discount percentage 0% of the first $2,500 Experience rating modification X Modified premium =$ - 9.1% of the next 11.3% of the next $47,500 $387,500 Aircraft seat surcharge - See instructions Maximum of 10 seats per aircraft seats X $ 25 = Subtotal premium Subtract premium discount < $ $ $ $ > 12.3% of all over $437,500 Net premium = Subtotal assessment payable net premium X WCD assessment rate* 0.0 % *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 . . . .< $ ... 0.00 0.00 > Total payment due $ 0.00 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. BIN Signature Name (print or type) E-mail address Return with payment to: Department of Consumer & Business Services Fiscal and Business Services P.O. Box 14610 Salem, OR 97309-0445 440-937 (5/12/DCBS/WCD/WEB) Date Title (print or type) Phone number DCBS use only: 31110 / 0463 Fax number American LegalNet, Inc. www.FormsWorkFlow.com Premium discount formula On premium of $ Discount Portion above $437,500 Next $387,500 Next $47,500 First $2,500 12.3% 11.3% 9.1% 0.0% $ $ $ $ Discount - $ $ $ - $ - American Leg
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