District Of Columbia > Workers Comp
Quarterly Premium Surcharge Payment Form - District Of Columbia
| Quarterly Premium Surcharge Payment Form Form. This is a District Of Columbia form and can be used in Workers Comp . |
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QUARTERLY PREMIUM SURCHARGE PAYMENT FORM Insurer Name__________________________________________________________________ Address_______________________________________________________________________ City____________________________ State_________________ Zip Code__________ Insurer NCCI Number________________________________ Date of Report Quarter Ending Date Dollar Amount Submitted ______________________________________________ CERTIFYING OFFICIAL (Type Name) ______________________________________________ CERTIFYING OFFICIAL (Signature) ______________________________________________ TITLE __________________________ TELEPHONE NUMBER Mail Form and Check to: D.C. Department of Employment Services Office of the Chief Financial Officer 64 New York Avenue, N.E., Suite 3093 Washington, D.C. 20002 (Telephone: 202-671-1400) Submit a Copy of the Form to: D.C. Department of Employment Services Office of Workers' Compensation Post Office Box 56098, Insurance Unit Washington, D.C. 20011 (FAX: 202-671-1929) ___________________ DATE (1) (2) Checks are payable to the D.C. Treasurer. This form may be reproduced or downloaded from the DOES website. The website address is www.does.dc.gov . American LegalNet, Inc. www.USCourtForms.com American LegalNet, Inc. www.USCourtForms.com
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