Oregon > Workers Comp > Self Insured Employer
Workers Compensation Payroll And Assessment Quarterly Report Retrospective Rating Plan 900 - Oregon
| Workers Compensation Payroll And Assessment Quarterly Report Retrospective Rating 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 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 $ Page 1 440-900 (5/11/DCBS/WCD/WEB) - TOTAL $ (continued on Sheet 2) - American LegalNet, Inc. www.FormsWorkFlow.com 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 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ PAGE SUBTOTAL $ TOTAL $ Page 1.1 440-900 (5/11/DCBS/WCD/WEB) - SUBTOTAL $ TOTAL $ (continued on Sheet 2) - American LegalNet, Inc. www.FormsWorkFlow.com 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 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ PAGE SUBTOTAL $ TOTAL $ Page 1.2 440-900 (5/11/DCBS/WCD/WEB) - SUBTOTAL $ TOTAL $ (continued on Sheet 2) - American LegalNet, Inc. www.FormsWorkFlow.com 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 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ PAGE SUBTOTAL $ TOTAL $ Page 1.3 440-900 (5/11/DCBS/WCD/WEB) - SUBTOTAL $ TOTAL $ (continued on Sheet 2) - American LegalNet, Inc. www.FormsWorkFlow.com 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 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ PAGE SUBTOTAL $ TOTAL $ Page 1.4 440-900 (5/11/DCBS/WCD/WEB) - SUBTOTAL $ TOTAL $ (continued on Sheet 2) - American LegalNet, Inc. www.FormsWorkFlow.com 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 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ PAGE SUBTOTAL $ TOTAL $ Page 1.5 440-900 (5/11/DCBS/WCD/WEB) - SUBTOTAL $ 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 seats X $25 X 0.0 % WCD rate* = $ 0.00 See instructions (Maximum of 10 seats per aircraft) Subtotal assessment payable Debit balance forward per DCBS Apply previous credit balance: $ $ 0.00 Credit balance per DCBS Subtract credit amount to be applied < New credit balance $ $ $ . > . . . . . . . Subtract . . <. $ 0.00 0.00 > Total payment due $ 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. 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 Page 2 440-900 (5/11/DCBS/WCD/WEB) Date Title (print or type) Phone number DCBS use only: 31110 / 0459 Fax number American LegalNet, Inc. www.FormsWorkFlow.com 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 4.8
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