HomeMy WebLinkAbout20202318.tiffCOLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
DIVISION OF WORKERS' COMPENSATION
WC112 Self -insured Surcharge Form
Confirmation Number
5kg284v
Filing Period:
January -June 2020
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 Raimer
Contact Phone:
970-400-4233
Contact Email:
mraimer@co.weld.co.us
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2020-2318
PEoo 3
Total Of Payroll Premium Equivalents
$ 1,004,605.39
Premium Equivalent less Deductible is the Subject Premium
$ 812,725.76
Subject Premium times NCCI Experience Mod = Modified Premium 0.84
$ 682,689.64
Modified Premium times Rating discount = Standard Premium
S 634,901.36
Surcharge Premium: Standard premium minus the discount is the Surcharge Premium
$ 563,157.51
Surcharge Premium times rate = surcharge due
$ 8,165.78
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 8-44-1 12, 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.
Michelle Raimer
Weld County Commissioner Mike Freeman 'JUL 2 7 2020
President or Chief Officer
Esther Gesick
Secretary or Chief Agent
Michelle Raimer
Division of Workers' Compensation
633 17th Street, Suite 900
Denver, CO 80202-3626
(303) 318-8767 FAX (303) 318-8778
Name of Contact Person (print)
Phone Number
970-400-4233
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