HomeMy WebLinkAbout20182491.tiffCOLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
DIVISION OF WORKERS' COMPENSATION
WC112 Self -insured Surcharge Form
Confirmation Number
2vrvcfo
Filing Period:
January -June 2018
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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2018-2491
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Total Of Payroll Premium Equivalents
$ 829,244.49
Premium Equivalent less Deductible is the Subject Premium
$ 703,199.33
Subject Premium times NCCI Experience Mod = Modified Premium 1.15
$ 808,679.23
Modified Premium times Rating discount = Standard Premium
$ 752,071.68
Surcharge Premium: Standard premium minus the discount is the Surcharge Premium
$ 667,087.58
Surcharge Premium times rate = surcharge due
$ 6,670.88
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.
Notary Seal
Subscribed and sworn to before me this 3/.s -
day of e„.44.3/
Notary Public
My commission expires
a9, .2i
Weld County Commissioner Steve Moreno
President or Chief Officer
Esther Gesick
Secretary or Chief Agent
Michelle Raimer
970-400-4233
Name of Contact Person (print) Phone Number
ESTHER E. GESICK
NOTARY PUBLIC
STATE OF COLORADO
NOTARY ID 19974016478
MY COMMISSION EXPIRES SEPT. 29, 2021
Division of Workers' Compensation
P.O. Box 628
Denver, CO 80201-0628
(303) 318-8771 FAX (303) 318-8778
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