Idaho > Workers Compensation > Surety
Semi Annual Report Workers Compensation Tax Report For Self Insured Employers IC-4010 - Idaho
| Semi Annual Report Workers Compensation Tax Report For Self Insured Employers 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 TAX REPORT FOR SELF-INSURED EMPLOYERS Street Address: 700 S Clearwater Lane Boise, ID 83712 FOR PERIOD ENDING_______________ Self-Insurer's Name ________________________________________________________________ Premium Tax Contact Person ________________________________________________________ Telephone _________________ Fax ________________________ Toll Free __________________ Address _________________________________________________________________________ City _____________________________________________ State ________ Zip Code __________ 1. Total Gross Wages (IC Form 4010A, Line 1) 2. Net Premium Equivalent (IC Form 4010A, Line 10) 3. Tax Rate 2.0% 4. Premium Tax Due (IC Form 4010A, Line 12) $ _________________ $ _________________ $ _________________ $ _________________ *0LQLPXP 7D[ 'XH $)),'$9,7 ________________________________, 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 the gross wages, premium tax equivalent, and premium taxes due for the period set forth above. _____________________________________________ (Signature of Corporate Officer) Subscribed and sworn to before me this _____ day of ___________________________, ________ NOTARY PUBLIC ____________________________ Residing at _________________________________ 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. /$7( 3$<0(17 3(1$/7< RI WKH RULJLQDO DPRXQW GXH WLPHV WKH QXPEHU RI WHQGD\ SHULRGV RU SRUWLRQV WKHUHRI ZKLFK KDYH HODSVHG VLQFH 0DUFK RU -XO\ GHSHQGLQJ RQ WKH 25,*,1$/ 72 7+( ,1'8675,$/ &200,66,21 UHSRUWLQJ SHULRG ,& 5(9,6(' 5(7$,1 $ &23< )25 <285 5(&25'6 American LegalNet, Inc. www.FormsWorkFlow.com
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