South Carolina Workers' Compensation Commission SELF-INSURANCE DIVISION 1333 Main Street, Suite 500 P.O. BOX 1715 Columbia, SC 29202-1715 (803) 737-5706 SOUTH CAROLINA SELF-INSURANCE TAX FORM DEADLINE FOR FILING IS THE FIFTEENTH DAY OF THE THIRD MONTH FOLLOWING THE CLOSE OF THE SELF-INSURER'S FISCAL YEAR Self-Insurance Number Name of Company Federal Employer ID # COMPUTATION OF TAX (See instructions.) # of employees in S.C.: to (Enter Fiscal Year) A. B. C. Total Medical Expense Paid Total Compensation Paid TOTAL MEDICAL AND COMPENSATION PAID (A + B) D. E. F. G. H. Expenses (Attach a list of expenses) Second Injury Fund Assessment Second Injury Recoveries Other Third Party Recoveries TOTAL ASSESSMENT LESS RECOVERIES (E ­ F ­ G) I. TOTAL COST OF SELF-INSURANCE ( C + D + H) J. TAX (2.5% X Line I) $ 0.00 $ 0.00 $ $ $ $ 0.00 $ $ $ $ 0.00 Attach a list of all subsidiaries and their federal employer identification numbers covered by this self-insurance plan. STATE OF COUNTY OF Personally appeared before me, statement of the actual cost incurred by the self-insurer. SWORN to and subscribed before me this day of , . SIGNATURE Notary Public ­ My Commission Expires: TITLE *MAKE CHECKS PAYABLE TO S.C. WORKERS' COMPENSATION COMMISSION* Complete and Return To: South Carolina Workers' Compensation Commission Director, Self-Insurance 1333 Main Street, Suite 500 · Post Office Box 1715 Columbia, South Carolina 29202-1715 (Officer) of the said who, upon oath, affirms that the above is a true and correct WCC Form # 10 Rev. 07/92 10 SOUTH CAROLINA SELF-INSURANCE TAX FORM American LegalNet, Inc. www.FormsWorkFlow.com SOUTH CAROLINA WORKERS' COMPENSATION COMMISSION INSTRUCTIONS FOR COMPLETING TAX FORM 10 SECTION I Complete all requested information. If not applicable, insert N/A in the blank. Be sure to furnish all entities covered by your self-insurance program and their federal identification numbers. The Commission uses the tax mailing address for all correspondence. Please notify the Commission of any necessary changes in the mailing address, contact person and/or phone number. SECTION II A. Include all medical claims paid during the taxable year, disregarding the date of the accident and/or the date of the claim. B. Include all compensation claims paid during the taxable year, disregarding the date of the accident and/or the date of the claim. C. Add Item A and Item B (Do not make any adjustment for recoveries). This item is automatically calculated in Word. D. Enter total costs of the self-insurance program, including the cost of bonds, excess insurance, administration (including clerical, office space, telephone expenses, etc.), and legal costs. If self-insurance operations are combined with other operations, pro-rate expenses. If costs are estimated, specify which costs are estimated and the method used. Attach a separate sheet itemizing all expenses. E. Enter Second Injury Fund Assessment. F. Enter recoveries from Second Injury Fund. G. Enter recoveries received from other Third Parties. H. Enter total of Items E less F less G. This item is automatically calculated in Word. I. J. Add Items C, D and H. This item is automatically calculated in Word. Multiply Item I by 2.5%. This item is automatically calculated in Word. SECTION III The tax form must be signed by an authorized officer of the company and notarized. A. Forward remittance, in the amount of Item J, along with the original SCWCC 10 tax form with attachments to the address on the front of this form. Checks should be made payable to the South Carolina Workers' Compensation Commission. B. The tax return must be postmarked no later than the fifteenth day of the third month following the close of the selfinsurer's fiscal year. Failure to file by this date will result in penalties and interest as provided in Section 42-5-190, and possible revocation of self-insurance privileges. C. Please direct all questions to: South Carolina Workers' Compensation Commission Director, Self-Insurance (803) 737-5706 WCC Form # 10 Rev. 07/92 10 SOUTH CAROLINA SELF-INSURANCE TAX FORM American LegalNet, Inc. www.FormsWorkFlow.com