HomeMy WebLinkAbout000302.tiff COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
DIVISION OF WORKERS' COMPENSATION
WC112 Self-insured Surcharge Form
Confirmation Number adq6v
Filing Period: July-December 2017
Filing Type: WC112
Company Name: Weld County
FEIN: 84-6000813
Block Number:
Street Address: 1150 O Street
Suite:
City: Greeley
State: CO
Zip Code: 80631
Address changed since last filing? No
President or Chief Officer: Weld County Commissioner Steve Moreno
Secretary or Chief Agent: Esther Gesick
Other Contact Person: Michelle Raimer
Contact Phone: 970-400-4233
Contact Email:
mraimer@co.weld.co.us
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Total Of Payroll Premium Equivalents $ 816,906.85
Premium Equivalent less Deductible is the Subject Premium $ 690,286.29
Subject Premium times NCCI Experience Mod=Modified Premium 1.11 $ 766,217.78
Modified Premium times Rating discount =Standard Premium $ 712,582.53
Surcharge Premium: Standard premium minus the discount is the Surcharge Premium $ 632,060.71
Surcharge Premium times rate=surcharge due $ 6,320.61
We,the undersigned President and Secretary(or other chief officers or agents) of the corporation for which this return is
made, being severally duly sworn, each for himself/herself, deposes and says that this return has been examined by
him/her and is to the best of his/her knowledge,information and belief, a true, correct and complete return made pursuant
to provisions of The Colorado Workers' Compensation Act,Colorado Revised Statutes, Sections 8-44-112, 8-46-102 and
8-46-202. ....
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Weld County Commissioner Steve Moreno
Notary Seal i� •act • "�,`�.-. ;'
'� •President •or Chief Officer
"o% 4.4°7 Esther Gesick editt.2
'") \/ Secretary or Chief Agent
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'''i "• Michelle Raimer 970-400-4233
Subscribed and sworn to before me this
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Name of Contact Person(print) Phone Number
day of `Ja UaY/ , /
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Nota Public
My commission expires / — a
KARLA FORD
NOTARY PUBLIC Division of Workers'Compensation
STATE OF COLORADO P.O'.Box 628
NOTARY ID 19984029774 Denver,CO 80201-0628
`?N EXPIRES DECEMBER 2,2018 (3O3)318-8771 FAX(303)318-8778
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