Self Insured Employer Semi Annual Premium Tax Computation
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Self Insured Employer Semi Annual Premium Tax Computation Form. This is a Idaho form and can be use in Surety Workers Compensation.
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Tags: Self Insured Employer Semi Annual Premium Tax Computation, IC-4010A, Idaho Workers Compensation, Surety
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
Index No.
Self-Insured Employer Semi-Annual Premium Tax Computation
:
Calendar No.
Period Ending _______________________________________
:
Self-Insured Name ____________________________________ JUDICIAL SUBPOENA
FEIN #______________________
Plaintiff(s)
Wholly-Owned Subsidiary Name _________________________ FEIN #______________________
-against:
Company Contact
Phone #
Fax #
:
SECTION A - ITEMIZATION OF DEDUCTIONS
1. Total Gross Wages (Reconciliation of amount reported
:
to the Idaho Department of Labor attached. Includes
Defendant(s)
:
federal. "cafeteria .plan". deductions). . . . . . . . . . . . . . . .
........... ......... .... ...........
$
Deductions
2. Overtime in excess of regular wages
THE PEOPLE OF THE STATE OF NEW YORK
TO
$
3. Executive Officers (Section 72-212(6) Idaho code)
$
4. Unworked Severance Pay
$
5. Other
GREETINGS: "as defined by NCCI Rules"
$
6. TOTALCOMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
WE DEDUCTIONS
,
the Honorable
at the
Court
$
located at
County of premium Wages "should match total wages by
7. Net
in room classifications, Sectionof
, on the
day B"
, 20
, at
o'clock in the
noon, and at any recessed
job
or adjourned date, to testify and give evidence as a witness in this action on the part of the
$
SECTION B - COMPUTATION OF TAX
NCCI
CODE
NO. OF
WORKERS' COMPENSATION
Your failure to comply with this subpoenaWAGES BY JOB as a contempt of court and will make you liable to
is punishable
RATE
WORKERS
CLASSIFICATION
PREMIUM
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
result of your failure to comply.
DESCRIPTION OF CLASSIFICATION
Witness, Honorable
Court in
County,
, one of the Justices of the
day of
, 20
(Attorney must sign above and type name below)
Attorney(s) for
8.
9.
10.
11.
12.
Subtotals
Less, Premium Discount # (See Premium Discount
Office and(-)
P.O. Address
Schedule Enclosed)
Net Premium Equivalent
(=)
Tax Rate (2.5%)
(X)
Telephone No.:
Premium Tax Due
(=)
0.025
Facsimile No.:
E-Mail Address:
Premium Discount Formula - (NCCI Basic Manual Rule V11-D)
Mobile Tel. No.:
IC 4010A, Revised 5/97
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