Workers Compensation Insurer Premium Assessment Report To Department Of Consumer And Business Services
Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Workers Compensation Insurer Premium Assessment Report To Department Of Consumer And Business Services Form. This is a Oregon form and can be use in Insurer And Self Insurer Workers Comp.
Loading PDF...
Tags: Workers Compensation Insurer Premium Assessment Report To Department Of Consumer And Business Services, 910, Oregon Workers Comp, Insurer And Self Insurer
Workers' Compensation Insurer
Premium Assessment Report to
Department of Consumer and Business Services
Fiscal and Business Services
P.O. Box 14610, Salem, OR 97309-0445
503-947-7941
Insurance company name and address (do not leave blank):
Name:
For calendar quarter ending:
Address:
Oregon WCD carrier no.:
1. a. Earned premium [from Annual Statement, Oregon Exhibit of Premiums and Losses
(Statutory Page 14), column 2, line 16, quarter's portion] If no premiums
were earned, enter "None."
$
(
b. Less exempted earned premium*
)
-
$
c. Plus large deductible premium credits applied for the period
$
-
d. Assessable earned premium (total of Lines 1a, 1b, and 1c)
$
2. Current assessment percentage
0.00%
3. Subtotal premium assessment due (Line 1d x Line 2)
$
$
(
5. Total premium assessments due (total of Lines 3 and 4)
-
$
4. Credit balance from previous quarters
-
-
Place all negative amounts in parentheses.
*Exempted earned premium: Premiums earned on insurance under jurisdiction
of the federal government (e.g., U.S. Longshore and Harbor Workers'
Compensation Act, Federal Employer's Liability Act, and Jones Act), and
employer liability increased limits premium as reported in the insurer's Annual
Statement, Exhibit of Premiums and Losses (Statutory Page 14), Business in the
State of Oregon, Column 2 Direct Premiums Earned, Line 16 Workers'
Compensation. All exempted earned premium must be stated on a direct basis
prior to reinsurance transactions.
FISCAL USE ONLY: 31110/0457
Preparer's signature
Date
Please print:
Name:
Title:
Phone:
Fax:
E-mail:
440-910 (7/11/DCBS/WCD/WEB)
American LegalNet, Inc.
www.FormsWorkFlow.com
)
