HomeMy WebLinkAbout20200526.tiffCOLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
DIVISION OF WORKERS' COMPENSATION
WC112 Self -insured Surcharge Form
Confirmation Number
6pmfo5j
Filing Period:
July -December 2019
Filing Type:
WC112
Company Name:
Weld County
FEIN:
84-6000813
Block Number:
846
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 Mike Freeman
Secretary or Chief Agent:
Esther Gesick
Other Contact Person:
Michelle Rainier
Contact Phone:
970-400-4233
Contact Email:
mraimer@co.weld.co.us
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2020-0526
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Total Of Payroll Premium Equivalents
$ 901, 979.15
Premium Equivalent less Deductible is the Subject Premium
$ 739,622.91
Subject Premium times NCCI Experience Mod = Modified Premium 0.92
$ 680,453.07
Modified Premium times Rating discount = Standard Premium
$ 612,407.77
Surcharge Premium: Standard premium minus the discount is the Surcharge Premium
$ 543,205.69
Surcharge Premium times rate = surcharge due
$ 7,876.48
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.
By checking this box and completing the online
filing, we, the undersigned President and
Secretary (or other chief officer or agents) of the
entity for which this return is made, being
severally duly sworn, each for himself/herself,
deposes and says that the information provided
has been examined by him/her and is to the best
of his/her knowledge, information and belief,
true, correct and complete made pursuant to the
provisions of The Colorado Workers'
Compensation Act, Colorado Revised Statutes,
Section 8-44-112, 8-46-102 and 8-46-202.
Weld CRyKs`-cminer Mike Freeman
President or Chief Officer
Esther Gesick
Secretary or Chief Agent rh
FEB 1 0 2020
Michelle Rainieyer����/ �ram
YEN'
Name of Contact Person (
Division of Workers' Compensation
633 17th Street, Suite 900
Denver, CO 80202-3626
(303) 318-8767 FAX (303) 318-8778
vi -P/1
970-400-4233
rint) Phone Number
6,5926.
Esther Gesick
From:
Sent:
To:
Cc:
Subject:
Michelle Raimer
Wednesday, January 29, 2020 11:17 AM
Esther Gesick
Don Warden
Self -insured Work Comp Online Surcharge Filing
Good morning Esther,
I'm forwarding a copy of the attached Colorado Dept of Labor & Employment (CDLE) Division of Work Comp (DOWC)
surcharge form for your records. This form includes you and Commissioner Kirkmeyer and is required for the County's
workers' compensation permit. The CDLE requires online reporting which is submitted via the state's confidential
portal.
Let me know if you need additional information regarding this form, the online filing process and/or the calculations
related to the surcharge. I don't believe this form requires BOCC presentation but may need to be indexed in Tyler. Call
me if you want to discuss Q
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MichelleR /mer
Risk Manager
Human Resources
P O Box 758
Greeley CO 80632
tel: : 970-400-4233
cell: 970-302-2423
fax: 970-400-4024
"Bringing out the best in our employees through sustained service and support."
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