Idaho > Workers Compensation > Surety
Self Insured Employer Semi Annual Premium Tax Computation IC-4010A - Idaho
| Self Insured Employer Semi Annual Premium Tax Computation Form. This is a Idaho form and can be used in Surety Workers Compensation . |
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Self-Insured Employer Semi-Annual Premium Tax Computation Period Ending _______________________________________ Self-Insured Name ___________________________________ _ FEIN #______________________ Wholly-Owned Subsidiary Name _________________________ FEIN #______________________ Company Contact Phone # Fax # SECTION A - ITEMIZATION OF DEDUCTIONS 1. Total Gross Wages (Reconciliation of amount reported to the Idaho Department of Labor attached. Includes federal "cafeteria plan" deductions) Deductions 2. Overtime in excess of regular wages 3. Executive Officers (Section 72-212(6) Idaho code) 4. Unworked Severance Pay 5. Other "as defined by NCCI Rules" 6. TOTAL DEDUCTIONS 7. Net premium Wages "should match total wages by job classifications, Section B" SECTION B - COMPUTATION OF TAX NCCI CODE DESCRIPTION OF CLASSIFICATION $ $ $ $ $ $ $ WORKERS' COMPENSATION PREMIUM NO. OF WORKERS WAGES BY JOB CLASSIFICATION RATE 8. 9. 10. 11. 12. Subtotals Less, Premium Discount # (See Premium Discount Schedule Enclosed) Net Premium Equivalent Tax Rate (2.0%) Premium Tax Due (-) (=) (X) (=) 0.020 IC 4010A, Revised 4/12 Premium Discount Formula - (NCCI Basic Manual Rule V11-D) American LegalNet, Inc. www.FormsWorkFlow.com EXAMPLE COMPUTATION OF SEMI-ANNUAL PREMIUM DISCOUNT Total Premiums First Six Months (Should agree with Line 8 on IC 4010A) Projected Premiums for Second Six Months Annualized Premium 137,214.78 137,214.78 274,429.56 Discount Basis First $10,000 of Premium Next $190,000 of Premium Next $1,550,000 of Premium Over $1,750,000 of Premium Applied Total Percentage Premium 0.00% 9.10% 11.30% 12.30% 10,000.00 190,000.00 74,429.56 0.00 $ 274,429.56 Computed Discount $ $ 17,290.00 $ 8,410.54 $ $ 25,700.54 50% $12,850.27 Divided for one-half year Semi-Annual Premium Discount COMPUTATION OF PREMIUM TAX DUE Total Premiums First Six Months (Should agree with Line 8 on IC 4010A) Semi-Annual Premium Discount (Should agree with Line 9 on IC 4010A) Net Premium Equivalent ( Should agree with Line 10 on IC 4010A) Tax Rate (2%) Premium Tax Due (Should agree with Line 12 on IC 4010A) $137,214.78 (12,850.27) 124,364.51 2% $2,487.29 If you need assistance, please contact one of the following Financial Specialists: Therese Ryan at (208) 334-6095 or Dianne Johnson at (208) 334-6026. Risk Rates - Period Ending 06-30-12 and 12-31-12 Page 1 08/07/2012 DMJ American LegalNet, Inc. www.FormsWorkFlow.com
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