HomeMy WebLinkAbout20172721.tiffCOLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
DIVISION OF WORKERS' COMPENSATION
WCI 12 Self -insured Surcharge Form
Confirmation Number
421100g
Filing Period:
January -June 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 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
dn.(2-eAti- 6alc,"(4,
S- 7 - Zoi 1
e-;q6(ittg-.)
7-02-017
2017-2721
PE603a-
Total Of Payroll Premium Equivalents
$ 792,468.12
Premium Equivalent less Deductible is the Subject Premium
$ 669,635.56
Subject Premium times NCCI Experience Mod = Modified Premium 1.07
$ 716,510.05
Modified Premium times Rating discount = Standard Premium
$ 666,354.34
Surcharge Premium: Standard premium minus the discount is the Surcharge Premium
$ 591,056.30
Surcharge Premium times rate = surcharge due
$ 3,546.34
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.
KARLA FORD
STA agAI D
4
env COMMISSION EXPIRES DECEMBER 2,
Subscribed and sworn to before me this
day of J(.(.kl
ai a tut
No Public
My commission expires ( p -j
Name of Contact Person (print)
Phone Number
gD/7
- Jig
eld County Commissione a Cozad
President or Chief Officer
Esther Gesick
Secretary or Chief Agent
Michelle Raimer
Division of Workers' Compensation
P.O. Box 628
Denver, CO 80201-0628
(303) 318-8771 FAX (303) 318-8778
970-400-4233
Hello