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Workers Compensation Payroll And Assessment Quarterly Report Normal Plan (5-06) Form. This is a Oregon form and can be use in Self Insured Employer Workers Comp.
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Tags: Workers Compensation Payroll And Assessment Quarterly Report Normal Plan (5-06), 937, Oregon Workers Comp, Self Insured Employer
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
Normal Plan
4-digit
insurer no.:
Self-insured employer
Name:
BIN:
Address:
Class
For quarter
ending:
Payroll description
Gross payroll
(to nearest dollar)
TOTAL $
440-937 (5/06/DCBS/WCD/WEB)
-
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
-
TOTAL $
-
(continued on Page 2)
American LegalNet, Inc.
www.FormsWorkflow.com
Page 2
Self-insured employer name
Total employer's
premium (from Pg.1)
$
-
Premium discount percentage
0% of the first
$2,500
9.1% of the next
11.3% of the next
Experience
rating
modification
X
-
Aircraft seat surcharge - See instructions
Maximum of 10 seats per aircraft
seats X $ 25
=
$387,500
$
-
Subtotal premium
$47,500
$
-
$
-
$
-
$
-
Subtract premium discount
12.3% of all over
Standard
premium
= $
$437,500
<
Net premium
Subtotal assessment payable net premium X WCD assessment rate*
0.0 %
=
>
*Assessment rates are established by OAR 440-045 and are published annually under separate bulletin.
Adjustment due
$
Apply previous credit balance:
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 due not later than the last calendar day of the month following quarter end date. A civil penalty will
automatically be assessed for late reports or payments.
List each legal entity for which payroll is being reported
BIN
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.
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
Date
Name (print or type)
Title (print or type)
E-mail address
Phone number
Return with payment to:
DCBS use only:
Fax number
31110 / 0451
Department of Consumer & Business
Services
Fiscal and Business Services
P.O. Box 14610
Salem, OR 97309-0445
440-937 (5/06/DCBS/WCD/WEB)
American LegalNet, Inc.
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Premium discount formula
On premium of
$
-
Portion above $437,500
Next $387,500
Next $47,500
First $2,500
12.3%
11.3%
9.1%
0.0%
$
$
$
$
Discount
-
Discount
$
$
$
-
$
-
American LegalNet, Inc.
www.FormsWorkflow.com
FY 2007
FY 2006
FY 2005
FY 2004
Class
FY 2007
Class
FY 2006
Class
FY 2005
Class
FY 2004
Code
Base Rate
Code
Base Rate
Code
Base Rate
Code
Base Rate
0005
1.92
0005
1.94
0005
2.00
0005
2.09
0008
3.10
0008
3.10
0008
3.10
0008
2.90
0016
4.49
0016
4.77
0016
4.91
0016
4.85
0034
2.91
0034
3.29
0034
3.47
0034
3.39
0035
2.10
0035
1.82
0035
1.87
0035
1.77
0036
5.61
0036
5.38
0036
4.97
0036
4.65
0037
5.25
0037
5.17
0037
4.99
0037
4.92
0042
4.47
0042
4.89
0042
5.13
0042
4.56
0050
9.10
0050
9.59
0050
9.11
0050
8.17
0079
3.02
0079
3.17
0079
2.89
0079
2.67
0083
12.70
0083
12.16
0083
12.53
0083
12.61
0106
11.32
0106
13.95
0106
13.62
0106
13.08
0113
2.72
0113
2.90
0113
2.91
0113
3.01
0117
0.42
0117
0.48
0117
0.52
0117
0.57
0124
6.84
0124
6.64
0124
6.86
0124
8.20
0169
6.55
0169
7.32
0169
7.32
0169
7.61
0170
3.27
0170
3.27
0170
3.24
0170
3.31
0251
5.69
0251
5.69
0251
4.67
0251
4.29
0917
4.67
0917
4.72
0917
4.02
0917
4.31
1005
6.89
1005
6.00
1005
5.63
1005
5.69
1016
19.83
1016
19.33
1016
19.60
1016
20.22
1164
10.05
1164
9.87
1164
12.01
1164
13.35
1165
5.08
1165
4.40
1165
4.15
1165
4.23
1320
3.06
1320
2.74
1320
2.95
1320
3.31
1322
12.88
1322
13.37
1322
12.79
1322
12.78
1430
5.66
1430
5.66
1430
4.77
1430
4.79
1438
2.32
1438
2.49
1438
2.75
1438
2.63
1452
1.87
1452
1.87
1452
1.64
1452
1.64
1463
8.56
1463
9.02
1463
8.51
1463
8.02
1472
2.82
1472
2.82
1472
2.61
1472
2.27
1624
9.48
1624
8.90
1624
8.40
1624
8.96
1642
3.72
1642
3.72
1642
3.13
1642
3.11
1654
10.75
1654
8.09
1654
6.53
1654
6.12
1655
5.70
1655
4.56
1655
4.33
1655
4.29
1699
2.31
1699
2.92
1699
3.54
1699
3.37
1701
3.43
1701
3.41
1701
3.22
1701
3.31
1710
8.15
1710
9.81
1710
10.88
1710
11.82
1741
2.27
1741
2.61
1741
2.70
1741
2.70
1747
2.48
1747
2.77
1747
2.47
1747
2.48
1748
2.68
1748
2.77
1748
2.96
1748
3.23
1803
4.51
1803
4.94
1803
4.41
1803
4.12
1852
1.73
1852
2.01
1852
2.10
1852
1.77
1860
1.61
1860
1.77
1860
1.98
1860
2.01
1924
2.17
1924
2.22
1924
2.15
1924
2.37
1925
4.43
1925
4.82
1925
4.38
1925
3.86
2001
2.78
2001
2.93
2001
2.63
2001
2.85
2002
4.66
2002
4.66
2002
4.39
2002
4.11
2003
2.25
2003
2003
2.52
2.45
2003
2.41
2014
2.90
2014
2014
3.75
3.72
2014
3.95
American LegalNet, Inc.
www.FormsWorkflow.com
2016
2021
2039
2041
2065
2070
2086
2089
2095
2104
2105
2110
2111
2112
2114
2121
2130
2131
2143
2150
2156
2157
2211
2220
2286
2288
2300
2302
2305
2361
2362
2380
2386
2388
2402
2413
2416
2417
2501
2503
2534
2570
2576
2578
2592
2600
2623
2651
2660
2670
2683
2688
2.37
2.76
4.24
2.19
2.26
3.57
4.42
5.47
2.70
4.56
2.27
2.14
2.22
1.98
2.92
2.57
3.30
2.12
2.16
6.60
4.91
4.91
5.03
2.09
1.77
3.85
2.54
1.73
1.61
1.66
1.91
3.12
1.40
1.93
4.02
2.32
1.84
2.06
1.76
1.22
2.01
4.09
4.24
4.70
2.66
2.14
3.78
1.45
2.48
2.54
3.14
2.08
2016
2021
2039
2041
2065
2070
2086
2089
2095
2104
2105
2110
2111
2112
2114
2121
2130
2131
2143
2150
2156
2157
2211
2220
2286
2288
2300
2302
2305
2361
2362
2380
2386
2388
2402
2413
2416
2417
2501
2503
2534
2570
2576
2578
2592
2600
2623
2651
2660
2670
2683
2688
2.37
2.76
4.88
2.32
3.36
4.17
4.66
5.88
3.54
5.40
2.27
2.25
2.22
2.29
3.36
2.51
3.37
2.06
2.40
6.84
4.66
5.21
5.03
2.14
1.77
4.48
2.91
1.73
1.61
1.81
2.03
4.28
1.51
2.05
4.19
2.32
1.91
1.96
1.51
1.22
2.29
4.09
4.65
4.80
3.00
2.22
4.39
1.63
2.73
3.02
3.00
2.40
2016
2021
2039
2041
2065
2070
2086
2089
2095
2104
2105
2110
2111
2112
2114
2121
2130
2131
2143
2150
2156
2157
2211
2220
2286
2288
2300
2302
2305
2361
2362
2380
2386
2388
2402
2413
2416
2417
2501
2503
2534
2570
2576
2578
2592
2600
2623
2651
2660
2670
2683
2688
1.96
2.78
4.39
2.32
3.63
4.62
4.78
5.83
3.81
5.97
2.27
2.54
2.22
2.27
3.69
2.16
3.38
1.63
2.53
6.26
3.66
4.16
5.03
2.11
1.88
4.26
3.03
1.64
1.51
1.63
2.23
4.12
1.57
2.05
4.11
1.98
1.71
1.89
1.51
1.16
2.29
3.67
4.08
3.78
2.65
2.24
5.37
1.89
2.87
3.21
3.02
2.33
2016
2021
2039
2041
2065
2070
2086
2089
2095
2104
2105
2110
2111
2112
2114
2121
2130
2131
2143
2150
2156
2157
2211
2220
2286
2288
2300
2302
2305
2361
2362
2380
2386
2388
2402
2413
2416
2417
2501
2503
2534
2570
2576
2578
2592
2600
2623
2651
2660
2670
2683
2688
1.75
2.78
4.01
2.32
3.48
4.76
5.24
5.83
3.98
6.00
2.29
2.57
2.22
2.50
4.51
1.95
3.49
1.45
2.60
6.19
3.55
3.28
5.03
2.08
1.84
3.92
3.12
1.62
1.53
1.54
2.13
4.03
1.62
2.36
3.24
1.98
1.81
2.01
1.56
1.06
2.29
3.55
3.95
2.98
2.54
2.39
5.90
1.87
2.95
3.28
3.02
2.29
American LegalNet, Inc.
www.FormsWorkflow.com
2697
2702
2703
2704
2710
2714
2725
2731
2735
2759
2790
2802
2812
2836
2841
2881
2883
2913
2915
2923
2942
2960
3004
3018
3022
3027
3028
3030
3040
3041
3042
3064
3066
3076
3081
3082
3085
3110
3111
3113
3114
3118
3122
3126
3131
3132
3145
3146
3168
3169
3175
3179
4.24
27.27
6.24
27.27
6.86
6.40
5.62
5.76
4.48
4.46
1.17
3.97
3.63
2.27
4.51
2.18
3.80
3.38
3.98
1.66
2.54
3.94
3.34
3.67
3.08
2.71
4.31
5.31
3.72
4.12
2.79
1.94
2.90
1.54
4.66
3.49
3.55
3.71
2.84
1.57
2.81
2.18
1.42
2.74
1.50
2.58
1.30
1.39
4.02
3.07
1.95
1.46
2697
2702
2703
2710
2714
2725
2731
2735
2759
2790
2802
2812
2836
2841
2881
2883
2913
2915
2923
2942
2960
3004
3018
3022
3027
3028
3030
3040
3041
3042
3064
3066
3076
3081
3082
3085
3110
3111
3113
3114
3118
3122
3126
3131
3132
3145
3146
3168
3169
3175
3179
3180
3.19
24.62
5.98
6.92
6.11
4.23
5.82
5.19
4.59
1.19
4.26
3.87
2.39
4.47
2.54
4.13
3.35
4.77
1.87
2.88
5.24
3.75
4.41
3.41
2.69
4.53
6.17
4.08
4.73
2.54
1.96
3.41
1.72
5.22
4.19
4.18
4.83
3.02
1.79
2.81
2.35
1.85
2.92
1.87
3.29
1.47
1.80
4.31
3.58
1.67
1.48
2.30
2697
2702
2703
2710
2714
2725
2731
2735
2759
2790
2802
2812
2836
2841
2881
2883
2913
2915
2923
2942
2960
3004
3018
3022
3027
3028
3030
3040
3041
3042
3064
3066
3076
3081
3082
3085
3110
3111
3113
3114
3118
3122
3126
3131
3132
3145
3146
3168
3169
3175
3179
3180
3.13
24.05
6.13
6.59
5.63
3.69
5.62
5.19
4.59
1.29
4.05
3.75
2.33
4.23
2.43
4.15
3.17
5.09
2.06
2.91
5.54
3.95
5.10
3.28
2.12
4.13
5.84
3.81
4.17
2.59
2.03
3.41
1.77
5.32
4.45
4.44
5.79
3.21
1.79
2.22
2.61
2.05
2.98
2.20
3.95
1.62
2.09
4.19
3.10
1.50
1.58
2.16
2697
2702
2703
2710
2714
2725
2731
2735
2759
2790
2802
2812
2836
2841
2881
2883
2913
2915
2923
2942
2960
3004
3018
3022
3027
3028
3030
3040
3041
3042
3064
3066
3076
3081
3082
3085
3110
3111
3113
3114
3118
3122
3126
3131
3132
3145
3146
3168
3169
3175
3179
3180
3.28
23.93
6.79
5.80
5.36
3.69
5.23
5.16
4.67
1.28
3.90
3.37
2.15
3.98
2.77
3.98
2.99
5.14
2.12
2.99
5.10
4.32
4.02
2.78
1.67
4.32
5.44
4.09
4.19
2.66
2.20
3.38
1.90
4.96
4.06
4.93
6.31
3.71
1.80
1.87
2.75
2.11
3.24
2.41
3.90
1.71
2.17
3.88
2.66
1.41
1.40
2.21
American LegalNet, Inc.
www.FormsWorkflow.com
3180
3188
3220
3223
3224
3227
3240
3241
3255
3257
3300
3303
3307
3315
3334
3336
3365
3372
3373
3383
3385
3400
3507
3548
3559
3574
3612
3620
3629
3632
3634
3635
3638
3642
3643
3647
3648
3681
3685
3719
3724
3726
3803
3807
3808
3821
3822
3824
3826
3830
3851
3865
2.01
2.07
1.66
3.38
4.18
2.14
1.81
2.84
2.79
1.74
4.22
4.14
2.64
2.14
3.03
1.73
7.94
4.00
4.12
1.41
1.07
2.54
3.76
1.91
1.97
0.73
2.92
3.26
1.60
2.64
1.64
2.10
1.63
1.06
2.04
1.72
1.70
1.01
0.89
2.47
7.29
7.43
2.88
1.88
3.84
3.67
3.59
4.17
0.64
2.00
1.68
2.52
3188
3220
3223
3224
3227
3240
3241
3255
3257
3300
3303
3307
3315
3334
3336
3365
3372
3373
3383
3385
3400
3507
3548
3559
3574
3612
3620
3629
3632
3634
3635
3638
3642
3643
3647
3648
3681
3685
3719
3724
3726
3803
3807
3808
3821
3822
3824
3826
3830
3851
3865
3881
2.24
1.85
3.09
4.57
2.06
1.87
3.54
3.54
2.43
4.22
4.27
2.78
2.51
3.54
1.60
8.59
3.80
4.52
1.45
1.11
3.15
3.85
2.08
2.14
0.77
3.02
3.57
1.94
3.06
1.80
2.16
1.75
1.26
2.22
1.62
1.96
1.08
0.91
2.47
7.07
7.74
3.74
2.31
4.20
4.28
3.94
4.45
0.64
1.71
2.16
3.03
3.18
3188
3220
3223
3224
3227
3240
3241
3255
3257
3300
3303
3307
3315
3334
3336
3365
3372
3373
3383
3385
3400
3507
3548
3559
3574
3612
3620
3629
3632
3634
3635
3638
3642
3643
3647
3648
3681
3685
3719
3724
3726
3803
3807
3808
3821
3822
3824
3826
3830
3851
3865
3881
2.43
1.85
2.60
4.06
1.95
1.90
3.45
3.54
2.67
4.29
4.04
2.88
2.82
3.60
1.38
8.48
3.95
3.79
1.42
1.05
3.34
3.88
1.84
2.26
0.73
2.38
3.91
1.93
3.04
1.78
2.07
1.76
1.28
2.22
1.50
1.86
0.99
0.91
2.47
7.24
8.25
3.92
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8810
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8824
8825
8826
8831
8832
8833
8835
8837
8842
8853
8868
8901
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3.48
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2.43
0.74
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3.88
3.56
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5.71
6.44
6.50
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11.28
6.31
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4.20
2.88
8.05
5.40
3.75
3.05
2.31
2.12
2.11
0.54
6.59
0.72
4.37
2.26
0.91
0.27
3.75
0.49
0.35
0.90
0.10
0.17
0.20
3.36
2.16
1.78
1.23
0.41
1.21
2.21
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2.06
0.47
0.31
0.21
2.55
8106
8107
8111
8112
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8215
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8232
8233
8263
8264
8265
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8288
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8293
8304
8350
8380
8385
8392
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8411
8500
8601
8606
8719
8720
8742
8745
8748
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8800
8803
8810
8820
8824
8825
8826
8831
8832
8833
8835
8837
8842
8853
8868
8901
8989
3.48
4.38
2.25
0.88
2.36
4.40
3.36
3.58
3.15
4.93
6.81
6.69
7.62
10.11
6.61
5.60
4.16
2.90
7.83
5.40
3.20
3.06
2.65
2.25
2.25
0.55
6.04
0.76
4.23
2.52
0.90
0.28
3.81
0.45
0.32
0.97
0.10
0.18
0.22
3.07
2.16
1.79
1.30
0.37
1.25
3.04
2.34
2.06
0.48
0.30
0.21
2.44
8106
8107
8111
8112
8116
8203
8209
8215
8227
8232
8233
8263
8264
8265
8279
8288
8291
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8293
8304
8350
8380
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8411
8500
8601
8606
8719
8720
8742
8745
8748
8755
8800
8803
8810
8820
8824
8825
8826
8831
8832
8833
8835
8837
8842
8853
8868
8901
8989
3.19
4.27
2.25
1.12
2.05
4.85
3.09
3.61
2.90
4.59
7.01
6.80
6.00
9.16
6.50
4.72
3.28
3.05
6.17
5.73
3.06
2.92
2.56
2.32
2.03
0.59
5.61
0.66
4.07
2.83
0.90
0.27
3.37
0.39
0.34
1.07
0.10
0.18
0.21
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American LegalNet, Inc.
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9040
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9061
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9079
9089
9093
9101
9102
9154
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9186
9220
9310
9311
9315
9328
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9366
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9470
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9501
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9516
9519
9521
9522
9534
9554
9586
9600
9620
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2.77
3.37
3.46
3.64
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1.33
2.13
1.87
0.91
0.92
1.57
1.25
1.75
3.46
3.77
1.97
1.58
6.89
35.41
7.84
2.02
11.10
2.87
11.59
6.22
3.64
4.72
2.58
2.45
6.90
6.49
1.09
2.08
1.63
2.14
2.47
1.20
2.33
2.86
1.82
2.57
4.24
1.95
14.22
12.67
1.13
1.66
1.67
9014
9015
9016
9019
9040
9052
9060
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9062
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9079
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9516
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9600
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10.54
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1.09
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5.20
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14.24
13.57
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1.66
1.74
9014
9015
9016
9019
9040
9052
9060
9061
9062
9063
9064
9079
9089
9093
9101
9102
9154
9156
9178
9179
9180
9182
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9220
9310
9311
9315
9328
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9402
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9410
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9516
9519
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9522
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3.34
3.41
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1.50
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21.48
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2.87
10.88
6.71
3.29
3.68
2.72
3.16
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5.66
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9016
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9040
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9060
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9522
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3.05
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3.23
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1.78
1.32
1.51
3.30
3.75
1.62
1.66
8.34
17.47
6.94
1.91
9.50
2.87
10.19
7.70
3.54
3.70
2.73
3.53
6.07
5.86
1.13
1.67
1.68
1.68
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American LegalNet, Inc.
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American LegalNet, Inc.
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American LegalNet, Inc.
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American LegalNet, Inc.
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American LegalNet, Inc.
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American LegalNet, Inc.
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American LegalNet, Inc.
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American LegalNet, Inc.
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American LegalNet, Inc.
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American LegalNet, Inc.
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American LegalNet, Inc.
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American LegalNet, Inc.
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American LegalNet, Inc.
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American LegalNet, Inc.
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American LegalNet, Inc.
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American LegalNet, Inc.
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American LegalNet, Inc.
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rate
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American LegalNet, Inc.
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American LegalNet, Inc.
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American LegalNet, Inc.
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American LegalNet, Inc.
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American LegalNet, Inc.
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American LegalNet, Inc.
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American LegalNet, Inc.
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American LegalNet, Inc.
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American LegalNet, Inc.
www.FormsWorkflow.com
American LegalNet, Inc.
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American LegalNet, Inc.
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American LegalNet, Inc.
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American LegalNet, Inc.
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American LegalNet, Inc.
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American LegalNet, Inc.
www.FormsWorkflow.com
American LegalNet, Inc.
www.FormsWorkflow.com
American LegalNet, Inc.
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American LegalNet, Inc.
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American LegalNet, Inc.
www.FormsWorkflow.com
American LegalNet, Inc.
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American LegalNet, Inc.
www.FormsWorkflow.com
American LegalNet, Inc.
www.FormsWorkflow.com
American LegalNet, Inc.
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American LegalNet, Inc.
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American LegalNet, Inc.
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American LegalNet, Inc.
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