HomeMy WebLinkAbout20170344.tiffCOLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
DIVISION OF WORKERS' COMPENSATION
WC112 Self -insured Surcharge Form
Confirmation Number
71oo1f9
Filing Period:
July -December 2016
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 Julie Cozad
Secretary or Chief Agent:
Esther Gesick
Other Contact Person:
Michelle Raimer
Contact Phone:
970-400-4233
Contact Email:
mraimer@co.weld.co.us
2017-0344
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P 0032-
Total Of Payroll Premium Equivalents
S 812,679.27
Premium Equivalent less Deductible is the Subject Premium
5 679,399.87
Subject Premium times NCCI Experience Mod = Modified Premium 1.07
S 726,957.86
Modified Premium times Rating discount = Standard Premium
S 690.609.97
Surcharge Premium: Standard premium minus the discount is the Surcharge Premium
S 61 571.n4
Surcharge Premium times rate = surcharge due
S 3,675.4'1
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
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Subscribed and sworn to before me this
day of Sanu0ru
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Notaf- Public
My commission expires`6 ig
J;
eld County Commissioner ,Julie Cozad
sident or Chief Officer
ther Gesick
ec retary nr chief Agent
Michelle Reimer-11\0W.,(1G
Name of Contact Person (print)
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Division of Workers' Compensation
P.O. Box 628
Denver, CO 80201-0628
ti303) 318-8771 FAX (303) 318-8778
970-400-4233
Phone Number
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