Colorado > Workers Comp
Payroll Statement Form WC112 - Colorado
| Payroll Statement Form Form. This is a Colorado form and can be used in Workers Comp . |
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COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT DIVISION OF WORKERS' COMPENSATION PAYROLL STATEMENT FORM January 1, 2012 June 30,2012 for the period beginning _______________ and ending ________________ Do Not Alter this Address Address Change or Correction Note: All executive officers are to be reported under their classification at an individual payroll of $910.00 per week. Class No. Manual Classification Number of Employees Payroll Rate Premium Equivalent TOTALS WC112 Rev 6/12 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Total Number Of Employees Total Payroll 1. 2. Total Of Payroll Premium Equivalents Premium Equivalent less Deductible, if applicable (see attachment 4), is the Subject Premium. Hazard Group Discounts: 1 = 26.4 % 2 = 21.7% 3 = 19.0% 3. 4. 5. 4 = 16.4% 5 = 14.0% 6 = 10.3% 7 = 7.9% _________% _________ % = Standard Premium $ $ $ $ $ Subject Premium times NCCI Experience Mod = Modified Premium Modified Premium times Rating discount of Surcharge Premium: The standard premium minus the discount described below is the Surcharge Premium. If standard premium (amount on line 4 above) is less than $100,000, discount is 9.1%; If standard premium is greater than $100,000 and less than $775,000, discount is 11.3%; If standard premium is greater than $775,000, discount is 12.3%. Standard premium minus this discount becomes the Surcharge Premium. ________% $ Surcharge Premium times rate (1.7%) = surcharge due $ 6. (The assessment of 1.7% is the combined total of two separate surcharges: the Major Medical and Subsequent Injury Funds at 0.1%; and the Cash Fund at 1.6%) We, the undersigned President and Secretary (or other chief officers or agents) of the corporation for which this return is made, being severally duly sworn, each for himself/herself, deposes and says that this return has been examined by him/her and is to the best of his/her knowledge, information and belief, a true, correct and complete return made pursuant to provisions of The Colorado Workers' Compensation Act, Colorado Revised Statutes, Sections 8-44-112, 8-46-102 and 8-46-202. Notary Seal Corporate Seal President or Chief Officer Secretary or Chief Agent Subscribed and sworn before me this day of Notary Public My commission expires , Name of Contact Person ) Phone Number ( Block Number Mail to: Division of Workers' Compensation P.O. Box 628 Denver, CO 80201-0628 (303) 318-8767 FAX (303) 318-8778 WC112 Rev 6/12 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com
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