Oregon > Workers Comp > Self Insured Employer
Workers Compensation Payroll And Assessment Quarterly Report Normal Plan (5-06) 937 - Oregon
| Workers Compensation Payroll And Assessment Quarterly Report Normal Plan (5-06) Form. This is a Oregon form and can be used in Self Insured Employer Workers Comp . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
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 Normal 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 $ 440-937 (5/06/DCBS/WCD/WEB) - TOTAL $ (continued on Page 2) - American LegalNet, Inc. www.FormsWorkflow.com Page 2 Self-insured employer name Total employer's premium (from Pg.1) $ - Premium discount percentage 0% of the first $2,500 Experience rating modification X Standard premium =$ - 9.1% of the next 11.3% of the next $47,500 $387,500 Aircraft seat surcharge - See instructions Maximum of 10 seats per aircraft seats X $ 25 = Subtotal premium Subtract premium discount < $ $ $ $ > 12.3% of all over $437,500 Net premium = Subtotal assessment payable net premium X WCD assessment rate* 0.0 % *Assessment rates are established by OAR 440-045 and are published annually under separate bulletin. $ Adjustment due Apply previous credit balance: $ 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. 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. BIN 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 440-937 (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 Premium discount formula On premium of $ Discount Portion above $437,500 Next $387,500 Next $47,500 First $2,500 12.3% 11.3% 9.1% 0.0% $ $ $ $ Discount - $ $ $ - $ - American LegalNet, Inc. www.FormsWorkflow.com FY 2007 FY 2006 FY 2005 FY 2004 Class FY 2007 Class FY 2006 Class FY 2005 Class FY 2004 Code Base Rate Code Base Rate Code Base Rate Code Base Rate 0005 1.92 0005 1.94 0005 2.00 0005 2.09 0008 3.10 0008 3.10 0008 3.10 0008 2.90 0016 4.49 0016 4.77 0016 4.91 0016 4.85 0034 2.91 0034 3.29 0034 3.47 0034 3.39 0035 2.10 0035 1.82 0035 1.87 0035 1.77 0036 5.61 0036 5.38 0036 4.97 0036 4.65 0037 5.25 0037 5.17 0037 4.99 0037 4.92 0042 4.47 0042 4.89 0042 5.13 0042 4.56 0050 9.10 0050 9.59 0050 9.11 0050 8.17 0079 3.02 0079 3.17 0079 2.89 0079 2.67 0083 12.70 0083 12.16 0083 12.53 0083 12.61 0106 11.32 0106 13.95 0106 13.62 0106 13.08 0113 2.72 0113 2.90 0113 2.91 0113 3.01 0117 0.42 0117 0.48 0117 0.52 0117 0.57 0124 6.84 0124 6.64 0124 6.86 0124 8.20 0169 6.55 0169 7.32 0169 7.32 0169 7.61 0170 3.27 0170 3.27 0170 3.24 0170 3.31 0251 5.69 0251 5.69 0251 4.67 0251 4.29 0917 4.67 0917 4.72 0917 4.02 0917 4.31 1005 6.89 1005 6.00 1005 5.63 1005 5.69 1016 19.83 1016 19.33 1016 19.60 1016 20.22 1164 10.05 1164 9.87 1164 12.01 1164 13.35 1165 5.08 1165 4.40 1165 4.15 1165 4.23 1320 3.06 1320 2.74 1320 2.95 1320 3.31 1322 12.88 1322 13.37 1322 12.79 1322 12.78 1430 5.66 1430 5.66 1430 4.77 1430 4.79 1438 2.32 1438 2.49 1438 2.75 1438 2.63 1452 1.87 1452 1.87 1452 1.64 1452 1.64 1463 8.56 1463 9.02 1463 8.51 1463 8.02 1472 2.82 1472 2.82 1472 2.61 1472 2.27 1624 9.48 1624 8.90 1624 8.40 1624 8.96 1642 3.72 1642 3.72 1642 3.13 1642 3.11 1654 10.75 1654 8.09 1654 6.53 1654 6.12 1655 5.70 1655 4.56 1655 4.33 1655 4.29 1699 2.31 1699 2.92 1699 3.54 1699 3.37 1701 3.43 1701 3.41 1701 3.22 1701 3.31 1710 8.15 1710 9.81 1710 10.88 1710 11.82 1741 2.27 1741 2.61 1741 2.70 1741 2.70 1747 2.48 1747 2.77 1747 2.47 1747 2.48 1748 2.68 1748 2.77 1748 2.96 1748 3.23 1803 4.51 1803 4.94 1803 4.41 1803 4.12 1852 1.73 1852 2.01 1852 2.10 1852 1.77 1860 1.61 1860 1.77 1860 1.98 1860 2.01 1924 2.17 1924 2.22 1924 2.15 1924 2.37 1925 4.43 1925 4.82 1925 4.38 1925 3.86 2001 2.78 2001 2.93 2001 2.63 2001 2.85 2002 4.66 2002 4.66 2002 4.39 2002 4.11 2003 2.25 2003 2003 2.52 2.45 2003 2.41 2014 2.90 2014 2014 3.75 3.72 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
|
|||||||
