Oregon > Workers Comp > Self Insured Employer
Workers Compensation Payroll And Assessment Quarterly Report Normal Plan 937 - Oregon
| Workers Compensation Payroll And Assessment Quarterly Report Normal Plan Form. This is a Oregon form and can be used in Self Insured Employer Workers Comp . |
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Department of Consumer and Business Services Fiscal and Business Services P.O. Box 14610 Salem, OR 97309-0445 503-947-7941 Workers' Compensation Payroll and 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 $ Page 1 - TOTAL $ (continued on Page 2) 440-937 (5/11/DCBS/WCD/WEB) 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 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ PAGE SUBTOTAL $ TOTAL $ Page 1.1 440-937 (5/11/DCBS/WCD/WEB) - SUBTOTAL $ TOTAL $ (continued on Page 2) 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 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ PAGE SUBTOTAL $ TOTAL $ Page 1.2 440-937 (5/11/DCBS/WCD/WEB) - SUBTOTAL $ TOTAL $ (continued on Page 2) 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 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ PAGE SUBTOTAL $ TOTAL $ Page 1.3 440-937 (5/11/DCBS/WCD/WEB) - SUBTOTAL $ TOTAL $ (continued on Page 2) 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 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ PAGE SUBTOTAL $ TOTAL $ Page 1.4 440-937 (5/11/DCBS/WCD/WEB) - SUBTOTAL $ TOTAL $ (continued on Page 2) 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 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ PAGE SUBTOTAL $ TOTAL $ Page 1.5 440-937 (5/11/DCBS/WCD/WEB) - SUBTOTAL $ TOTAL $ (continued on Page 2) Page 2 Self-insured employer name Total employer's premium (from Pg.1) $ Experience rating modification X Modified premium =$ Premium discount percentage 0% of the first $2,500 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. $ Debit balance forward per DCBS Apply previous credit balance: Credit balance per DCBS Subtract credit amount to be applied New credit balance $ <$ $ > . . . .Subtract . . . .< $ ... 0.00 Total payment due $ 0.00 > 0.00 This report is due not later than the last calendar day of the month following quarter end date. The director may assess a civil penalty for late reports or late 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 (5/11/DCBS/WCD/WEB) Date Title (print or type) Phone number DCBS use only: 31110 / 0459 Fax number Premium discount formula On premium of $ Portion above $437,500 Next $387,500 Next $47,500 First $2,500 12.3% 11.3% 9.1% 0.0% $ $ $ $ Discount $ $ $ Discount - $ - FY 2012 FY 2011 FY 2010 FY 2009 FY 2008 Class FY 2012 Class FY 2011 Class FY 2010 Class FY 2009 Class Code Base Rate Code Base Rate Code Base Rate Code Base Rate Code 0005 1.93 0005 1.85 0005 1.81 0005 1.70 0005 0008 1.84 0008 1.80 0008 2.04 0008 2.21 0008 0016 3.76 0016 3.78 0016 3.94 0016 3.97 0016 0034 3.48 0034 2.88 0034 2.66 0034 2.74 0034 0035 2.38 0035 2.36 0035 2.78 0035 2.63 0035 0036 3.30 0036 3.81 0036 4.58 0036 5.44 0036 0037 3.82 0037 4.01 0037 4.83 0037 5.14 0037 0042 4.14 0042 4.00 0042 4.22 0042 4.75 0042 0050 5.32 0050 5.56 0050 5.53 0050 5.63 0050 0079 3.
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