Workers Compensation Payroll And Assessment Quarterly Report Retrospective Rating Plan {900} | | Oregon

 Oregon   Workers Comp   Self Insured Employer 
Workers Compensation Payroll And Assessment Quarterly Report Retrospective Rating Plan {900} | | Oregon

Last updated: 12/2/2016

Workers Compensation Payroll And Assessment Quarterly Report Retrospective Rating Plan {900}

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Description

Department of Consumer and Business Services Central Services Division 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 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ TOTAL $ Page 1 440-900 (5/16/DCBS/W CD/W EB) Class Employer's premium 0.00 TOTAL $ 0.00 (continued on Sheet 2) American LegalNet, Inc. www.FormsWorkFlow.com

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