Oregon > Workers Comp > Self Insured Employer
Workers Compensation Payroll And Assessment Quarterly Report Retrospective Rating Plan (5-06) 900 - Oregon
| Workers Compensation Payroll And Assessment Quarterly Report Retrospective Rating Plan (5-06) Form. This is a Oregon form and can be used in Self Insured Employer Workers Comp . |
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Department of Consumer & Business Services Fiscal and Business Services P.O. Box 14610 Salem, Oregon 97309-0445 (503) 947-7941 Workers' Compensation Payroll & Assessment Quarterly Report Retrospective Rating Plan Self-insured employer Name: Address: Gross payroll (to nearest dollar) 4-digit insurer no.: BIN: For quarter ending: Payroll description Base rate 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 Employer's premium - Class $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ TOTAL $ 440-900 (5/06/DCBS/WCD/WEB) - TOTAL $ (continued on Sheet 2) - American LegalNet, Inc. www.FormsWorkflow.com Page 2 Self-insured employer name: Employer's total premium (from pg.1) Experience rating modification X = $ Standard premium X 80% X WCD assessment rate* 0.0 %= Assessment payable $ - $ *Assessment rates are established by OAR 440-045 and are published annually under separate bulletin. Aircraft seat surcharge Passenger seatsX $25 X 0.0 % WCD rate* = $ 0.00 See instructions (Maximum of 10 seats per aircraft) Subtotal assessment payable Adjustment due Apply previous credit balance: $ $ 0.00 Credit balance per DCBS Subtract credit amount to be applied < New credit balance $ $ $ . 0.00 > . . . . . . . Subtract . . <. $ 0.00 0.00 > Total payment due $ 0.00 This report due not later than the last calendar day of the month following quarter end date. A civil penalty will automatically be assessed for late reports or payments. List each legal entity for which payroll is being reported 1 2 3 4 5 6 7 8 9 10 If additional lines are needed, list entities on a separate sheet of paper and attach. BIN The undersigned hereby certifies that the figures appearing in the column of this report headed "Gross payroll" are a true and complete statement of the earnings of all your Oregon employees for the period stated. Signature Name (print or type) E-mail address Return with payment to: Department of Consumer & Business Services Fiscal and Business Services P.O. Box 14610, Salem, OR 97309-0445 440-900 (5/06/DCBS/WCD/WEB) Date Title (print or type) Phone number DCBS use only: 31110 / 0451 Fax number American LegalNet, Inc. www.FormsWorkflow.com FY 2007 Class FY 2007 Code Base Rate 0005 1.92 0008 3.10 0016 4.49 0034 2.91 0035 2.10 0036 5.61 0037 5.25 0042 4.47 0050 9.10 0079 3.02 0083 12.70 0106 11.32 0113 2.72 0117 0.42 0124 6.84 0169 6.55 0170 3.27 0251 5.69 0917 4.67 1005 6.89 1016 19.83 1164 10.05 1165 5.08 1320 3.06 1322 12.88 1430 5.66 1438 2.32 1452 1.87 1463 8.56 1472 2.82 1624 9.48 1642 3.72 1654 10.75 1655 5.70 1699 2.31 1701 3.43 1710 8.15 1741 2.27 1747 2.48 1748 2.68 1803 4.51 1852 1.73 1860 1.61 1924 2.17 1925 4.43 2001 2.78 2002 4.66 2003 2.25 2014 2.90 FY 2006 Class FY 2006 Code Base Rate 0005 1.94 0008 3.10 0016 4.77 0034 3.29 0035 1.82 0036 5.38 0037 5.17 0042 4.89 0050 9.59 0079 3.17 0083 12.16 0106 13.95 0113 2.90 0117 0.48 0124 6.64 0169 7.32 0170 3.27 0251 5.69 0917 4.72 1005 6.00 1016 19.33 1164 9.87 1165 4.40 1320 2.74 1322 13.37 1430 5.66 1438 2.49 1452 1.87 1463 9.02 1472 2.82 1624 8.90 1642 3.72 1654 8.09 1655 4.56 1699 2.92 1701 3.41 1710 9.81 1741 2.61 1747 2.77 1748 2.77 1803 4.94 1852 2.01 1860 1.77 1924 2.22 1925 4.82 2001 2.93 2002 4.66 2003 2.52 2014 3.75 FY 2005 Class FY 2005 Code Base Rate 0005 2.00 0008 3.10 0016 4.91 0034 3.47 0035 1.87 0036 4.97 0037 4.99 0042 5.13 0050 9.11 0079 2.89 0083 12.53 0106 13.62 0113 2.91 0117 0.52 0124 6.86 0169 7.32 0170 3.24 0251 4.67 0917 4.02 1005 5.63 1016 19.60 1164 12.01 1165 4.15 1320 2.95 1322 12.79 1430 4.77 1438 2.75 1452 1.64 1463 8.51 1472 2.61 1624 8.40 1642 3.13 1654 6.53 1655 4.33 1699 3.54 1701 3.22 1710 10.88 1741 2.70 1747 2.47 1748 2.96 1803 4.41 1852 2.10 1860 1.98 1924 2.15 1925 4.38 2001 2.63 2002 4.39 2003 2.45 2014 3.72 FY 2004 Class FY 2004 Code Base Rate 0005 2.09 0008 2.90 0016 4.85 0034 3.39 0035 1.77 0036 4.65 0037 4.92 0042 4.56 0050 8.17 0079 2.67 0083 12.61 0106 13.08 0113 3.01 0117 0.57 0124 8.20 0169 7.61 0170 3.31 0251 4.29 0917 4.31 1005 5.69 1016 20.22 1164 13.35 1165 4.23 1320 3.31 1322 12.78 1430 4.79 1438 2.63 1452 1.64 1463 8.02 1472 2.27 1624 8.96 1642 3.11 1654 6.12 1655 4.29 1699 3.37 1701 3.31 1710 11.82 1741 2.70 1747 2.48 1748 3.23 1803 4.12 1852 1.77 1860 2.01 1924 2.37 1925 3.86 2001 2.85 2002 4.11 2003 2.41 2014 3.95 American LegalNet, Inc. www.FormsWorkflow.com 2016 2021 2039 2041 2065 2070 2086 2089 2095 2104 2105 2110 2111 2112 2114 2121 2130 2131 2143 2150 2156 2157 2211 2220 2286 2288 2300 2302 2305 2361 2362 2380 2386 2388 2402 2413 2416 2417 2501 2503 2534 2570 2576 2578 2592 2600 2623 2651 2660 2670 2683 2688 2.37 2.76 4.24 2.19 2.26 3.57 4.42 5.47 2.70 4.56 2.27 2.14 2.22 1.98 2.92 2.57 3.30 2.12 2.16 6.60 4.91 4.91 5.03 2.09 1.77 3.85 2.54 1.73 1.61 1.66 1.91 3.12 1.40 1.93 4.02 2.32 1.84 2.06 1.76 1.22 2.01 4.09 4.24 4.70 2.66 2.14 3.78 1.45 2.48 2.54 3.14 2.08 2016 2021 2039 2041 2065 2070 2086 2089 2095 2104 2105 2110 2111 2112 2114 2121 2130 2131 2143 2150 2156 2157 2211 2220 2286 2288 2300 2302 2305 2361 2362 2380 2386 2388 2402 2413 2416 2417 2501 2503 2534 2570 2576 2578 2592 2600 2623 2651 2660 2670 2683 2688 2.37 2.76 4.88 2.32 3.36 4.17 4.66 5.88 3.54 5.40 2.27 2.25 2.22 2.29 3.36 2.51 3.37 2.06 2.40 6.84 4.66 5.21 5.03 2.14 1.77 4.48 2.91 1.73 1.61 1.81 2.03 4.28 1.51 2.05 4.19 2.32 1.91 1.96 1.51 1.22 2.29 4.09 4.65 4.80 3.00 2.22 4.39 1.63 2.73 3.02 3.00 2.40 2016 2021 2039 2041 2065 2070 2086 2089 2095 2104 2105 2110 2111 2112 2114 2121 2130 2131 2143 2150 2156 2157 2211 2220 2286 2288 2300 2302 2305 2361 2362 2380 2386 2388 2402 2413 2416 2417 2501 2503 2534 2570 2576 2578 2592 2600 2623 2651 2660 2670 2683 2688 1.96 2.78 4.39 2.32 3.63 4.62 4.78 5.83 3.81 5.97 2.27 2.54 2.22 2.27 3.69 2.16 3.38 1.63 2.53 6.26 3.66 4.16 5.03 2.11 1.88 4.26 3.03 1.64 1.51 1.63 2.23 4.12 1.57 2.05 4.11 1.98 1.71 1.89 1.51 1.16 2.29 3.67 4.08 3.78 2.65 2.24 5.37 1.89 2.87 3.21 3.02 2.33 2016 2021 2039 2041 2065 2070 2086 2089 2095 2104 2105 2110 2111 2112 2114 2121 2130 2131 2143 2150 2156 2157 2211 2220 2286 2288 2300 2302 2305 2361 2362 2380 2386 2388 2402 2413 2416 2417 2501 2503 2534 2570 2576 2578 2592 2600 2623 2651 2660 2670 2683 2688 1.75 2.78 4.01 2.32 3.48 4.76 5.24 5.83 3.98 6.00 2.29 2.57 2.22 2.50 4.51 1.95 3.49 1.45 2.60 6.19 3.55 3.28 5.03 2.08 1.84 3.92 3.12 1.62 1.53 1.54 2.13 4.03 1.62 2.36 3.24 1.98 1.81 2.01 1.56 1.06 2.29 3.55 3.95 2.98 2.54 2.39 5.90 1.8
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