Idaho > Workers Compensation > Surety
Semi Annual Report Workers Compensation Premium Tax IC-4008 - Idaho
| Semi Annual Report Workers Compensation Premium Tax Form. This is a Idaho form and can be used in Surety Workers Compensation . |
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STATE OF IDAHO INDUSTRIAL COMMISSION P.O. BOX 83720 BOISE. ID 83720-0041 SEMI-ANNUAL REPORT WORKERS' COMPENSATION PREMIUM TAX FOR THE PERIOD AND YEAR ____________ JANUARY- JUNE Street Address: 700 So. Clearwater Ln, Boise ID JULY - DECEMBER INSURANCE COMPANY: Contact Person: Address: City: Phone: Gross Premiums Written Less: Returned Premiums and Premiums on Policies Not Taken Net Premiums Written Tax Rate 2.0% Tax Due (Net Premiums x Tax Rate) FEIN: Title: State: Fax: $ (-) $ (=) $ (x) $ $ *Minimum Tax Due = $75.00 AFFIDAVIT , being first duly sworn, deposes and states that s/he is a corporate officer, with the title of , that this report is made under the provisions of Section 72-524, Idaho code, and under penalty of perjury; that the foregoing statement contains a full, true and accurate report of all workers' compensation premiums reportable on business written on risk insured in the State of Idaho during the period set forth above. Postal Code: .020 (Signature of Corporate Officer) State of County of ) ) ss. ) , Subscribed and sworn to before me this day of Residing at Notary Public My Commission Expires This report is due within 30 days after February 1 (by March 3) for the last six months of the preceding year, and within 30 days after July 1 (by July 31) for the first six months of the current year. LATE PAYMENT PENALTY- 10% of the original amount due times the number of ten-day periods or portions thereof which have elapsed since March 3 or July 31 depending upon the reporting period. Submit the original completed report to the Industrial Commission, a copy marked "COPY" to the Idaho Department of Insurance, and retain a copy for your records. IC 4008, Revised 5/12 American LegalNet, Inc. www.FormsWorkFlow.com
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