HomeMy WebLinkAbout20162528.tiffCOLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
DIVISION OF WORKERS' COMPENSATION
WC 112 Self -insured Surcharge Form
Confirmation Number
4fejg 1a
Filing Period:
January -June 2016
Filing Type:
WC112
Company Name:
Weld County
FEIN:
84-6000813
Block Number:
Street Address:
1150 O Street
Suite:
City:
Greeley
State:
CO
Zip Codc:
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@weldgov.com
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2016-2528
P6O3Z
Total Of Payroll Premium Equivalents
$ 770,815.89
Premium Equivalent less Deductible is the Subject Premium
$ 644,402.09
Subject Premium times NCCI Experience Mod = Modified Premium 1.07
$ 689,510.23
Modified Premium times Rating discount = Standard Premium
$ 655,034.72
Surcharge Premium: Standard premium minus the discount is the Surcharge Premium
$ 581,015.80
Surcharge Premium times rate = surcharge due
$ 3,486.09
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.
C
NOTARY ID 20054020344
MY COMMISSION EXPIRES MAY 19, 2017
Subscribed and sworn to before me this NfrA
day of
Notary
My commission expires
Weld County Commissioner Mike Freeman
President or Chief Officer
Esther Gesick
Secretary or Chief Agent
Michelle Raimer 970-400-4233
Name of Contact Person (print) Phone Number
EST: deedsi)v- •tik
CLERK TO THE BOARD
PUTY Cl
rkers' Compensation
P.O. Box 628
Denver, CO 80201-0628
(303) 318-877 i FAX (303) 318-8778
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