Colorado > Workers Comp
Surcharge Form WC113 - Colorado
| Surcharge 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 SURCHARGE FORM January 1, 2012 June 30, 2012 for the period beginning _______________ and ending _______________ Do Not Alter this Address Address Change or Correction 1 Total premium written on Colorado Workers' Compensation Insurance policies with deductibles less than $5,000, including excess coverage .............................................. 2 Plus premium on deductible policies over $5,000, reported on a $5,000 deductible basis ......... 3 Less total canceled or returned premiums ................................................................ 4 Net premiums subject to surcharge ........................................................................ 5 Net amount of Surcharge (1.73% of net premiums) .................................................... $ ______________ $ ______________ $ ______________ $ ______________ $ ______________ (The assessment of 1.73% is the combined total of three separate surcharges: the Major Medical and Subsequent Injury Funds at 0.1%; the Cash Fund at 1.6%; and the Premium Cost Containment Fund at .03 %.) 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 to before me this__________ Name of Contact Person (print) day of ________________________, ___________ __________________________________________ Notary Public My commission expires_______________________ FEIN Block # ( ) Phone Number NAIC # Mail to: Division of Workers' Compensation P.O. Box 628 Denver, CO 80201-0628 303.318.8767 FAX 303.318.8778 WC113 Rev 6/12 American LegalNet, Inc. www.FormsWorkFlow.com
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