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Annual Payroll Report Of City Town Or County Operating As A Self-Insurer 26C - Virginia
| Annual Payroll Report Of City Town Or County Operating As A Self-Insurer Form. This is a Virginia form and can be used in Workers Compensation . |
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FORM 26C-7/6/2011 COMMONWEALTH OF VIRGINIA WORKERS' COMPENSATION COMMISSION 1000 DMV DRIVE, RICHMOND, VIRGINIA 23220 ATTN: CHIEF FINANCIAL OFFICER Annual Payroll Report of City, Town or County Operating as a Self-Insurer Year Ended December 31, _______ Employer __________________________________________ Pursuant to the provisions of Section 65.2-1006 of the Workers' Compensation Act, this report must be prepared upon a calendar year basis and filed with the Workers' Compensation Commission by March 15th. All salaries and wages paid or due officials and employees for the calendar year, together with other remuneration, if any, must be reported including amounts paid temporary and part-time employees irrespective of the type of work done. See notes on back. CLASSIFICATION OF OPERATIONS Tree Pruning and Spraying, incl. Drivers Machine Shop Street or Road Construction, paving, resurfacing, incl. Drivers Street or Road Construction, clearing, excavation, incl. Drivers Sewer Construction, all operations, incl. Drivers Gas & Water Main & Connections-Construction, incl. Drivers Aircraft Ground Employees Gas Works, all operations (excl. construction of bldgs/gas holders) Waterworks Operation, all employees, incl. Drivers Sewerage Disposal Plant Operation, incl. Drivers Garbage Works-Reduction or Incineration Firefighters, incl. Drivers Law Enforcement Officers, incl. Drivers & Emergency Communication Technicians Automobile Repair Shops-all employees, incl. Drivers Engineers or Architects-not engaged in actual construction Clerical Office Employees (Court clerks, Comm. Atty., etc.) Dog Warden (kennel), incl. Drivers Hospital-Professional Employees Care, custody & maintenance of bldgs. & grounds Hospital-All employees other than professionals All other Library Employees Parks & Recreation Areas-All operations except new construction Cemetery Employees Sewer Cleaning, Street Cleaning, & Snow/Ice Removal & Drivers Garbage, Ashes or Refuse Collection, incl. Drivers Tax Collectors, Inspectors, Farm & Home Demonstration Agents Welfare, Case Workers-not office Space for other classifications available on reverse side Subtotal this page nd Subtotal 2 page Total of all payroll CLASS CODES 0106 3632 5506 5507 6306 6319 7403 7502 7520 7580 7590 7710 7720 8380 8601 8810 8831 8833 9015 9040 9101 9102 9220 9402 9403 9410 9411 Total Payroll for Twelve Mos. Ending December 31, _________ Signed this day __________________ by ________________________________________________________________________________ Date Signature of Representative and Title of ______________________________________________________________________________________ Name and Address of City, Town or County ________________________ Fed. Tax ID# This day ______________________________ personally appeared before me, acknowledged their signature, and made oath that the foregoing report is correct. Given under my hand and notarial seal this _________ day of ______________________, _________. Signature of Notary SEAL My commission expires _______________________ American LegalNet, Inc. www.FormsWorkFlow.com CLASSIFICATION OF OPERATIONS continued CLASS CODES PAYROLL AMOUNT Subtotal 2 nd page Note 1: The extra remuneration paid for overtime may be deducted; e.g. if time and a half paid for overtime, the half may be deducted. Note 2: New construction work and alterations done by employees of the municipality must be reported under the various construction classifications applicable, such as masonry, plumbing, sheet metal work, etc. Note 3: If you need to report for flying crew the Classification Code is 7421, however, when using 7421 you must also report the number of passenger seats using Classification Code 0088. Please enter the name and telephone number of the person to contact if we have any questions regarding this report. Please print. _____________________________________________________________ Name of Contact _____________________ Telephone # American LegalNet, Inc. www.FormsWorkFlow.com
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