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Workers Compensation Insurer Premium Assessment Report To Department Of Consumer And Business Services 910 - Oregon

Workers Compensation Insurer Premium Assessment Report To Department Of Consumer And Business Services Form. This is a Oregon form and can be used in Insurer And Self Insurer Workers Comp .
 Fillable pdf Last Modified 11/4/2011
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Workers' Compensation Insurer Premium Assessment Report to Department of Consumer and Business Services Fiscal and Business Services P.O. Box 14610, Salem, OR 97309-0445 503-947-7941 Insurance company name and address (do not leave blank): Name: Address: Oregon WCD carrier no.: For calendar quarter ending: 1. a. Earned premium [from Annual Statement, Oregon Exhibit of Premiums and Losses (Statutory Page 14), column 2, line 16, quarter's portion] If no premiums were earned, enter "None." $ b. Less exempted earned premium* c. Plus large deductible premium credits applied for the period d. Assessable earned premium (total of Lines 1a, 1b, and 1c) 2. Current assessment percentage 3. Subtotal premium assessment due (Line 1d x Line 2) 4. Credit balance from previous quarters 5. Total premium assessments due (total of Lines 3 and 4) Place all negative amounts in parentheses. *Exempted earned premium: Premiums earned on insurance under jurisdiction of the federal government (e.g., U.S. Longshore and Harbor Workers' Compensation Act, Federal Employer's Liability Act, and Jones Act), and employer liability increased limits premium as reported in the insurer's Annual Statement, Exhibit of Premiums and Losses (Statutory Page 14), Business in the State of Oregon, Column 2 Direct Premiums Earned, Line 16 Workers' Compensation. All exempted earned premium must be stated on a direct basis prior to reinsurance transactions. ( $ $ $ 0.00% $ ( $ $ ) ) FISCAL USE ONLY: 31110/0457 Preparer's signature Please print: Name: Title: Phone: Fax: E-mail: 440-910 (7/11/DCBS/WCD/WEB) Date American LegalNet, Inc. www.FormsWorkFlow.com
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