Fillable Payroll Statement Form (Colorado DORA)

Fill Online, Printable, Fillable, Blank Payroll Statement Form (Colorado DORA) Form

Use Fill to complete blank online COLORADO DORA pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Payroll Statement Form (Colorado DORA)

On average this form takes 32 minutes to complete

The Payroll Statement Form (Colorado DORA) form is 2 pages long and contains:

  • 0 signatures
  • 0 check-boxes
  • 128 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your DORA forms online.

Colorado Department of Regulatory Agencies (DORA) is responsible for professional licensing and consumer protection in Colorado USA.

BROWSE COLORADO DORA FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
WC112 Rev 12/20 Page 1 of 2
COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
DIVISION OF WORKERS’ COMPENSATION
Payroll Statement Form
for the period beginning July 1, 2020 and ending December 31, 2020
Do Not Alter this Address
Address Change or Correction
Note: All executive officers are to be reported under their classification at an individual payroll of $1,123.00 per week.
Class No.
Job Title Payroll
Rate
Premium
Equivale
nt
TOTALS
WC112 Rev 12/20
Total Number Of Employees
Total Payroll
$
1. Total Of Payroll Premium Equivalen
ts
$
2. Premium Equivalent less Deductible,
if applicable (see attachment 4), is the Subject Premium.
Hazard Group Discounts:
• 1 = 34.4%
• 2 = 29.5%
• 3 = 27.1%
• 4 = 22.4%
• 5 = 19.1%
• 6 = 16.1%
• 7 = 14.0%
_________%
$
3. Subject Premium times NCCI Experi
ence Mod = Modified Premium
_________ $
4. Modified Premium times Rating discount of 7.0% = Standard Premium
$
5.
Surcharge Premium:
The standard prem
ium minus the discount described below is the Surcharge Premium.
• If standard premium (amount on line 4 above) is less than $100,000, discount is 9.1%;
• If standard premium is greater than $100,000 and less than $775,000, discount is 11.3%;
• If standard premium is greater than $775,000, discount is 12.3%.
Standard premium minus this discount becomes the Surcharge Premium. ________% $
6. Surcharge Premium times rate (1.45%) = sur
charge due
$
(The assessment of 1.45% is the combined total of two separate surcharges: the Major Medical and
Subsequent Injury Funds at 0.10%; and the Cash Fund at 1.35%)
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 Corporate Seal
President or Chief Officer
Secretary or Chief Agent
Subscribed and sworn before me this
,
Notary Public
My commission expires
Name of Contact Person
Mail to
:
Division of Workers’ Compensation
633 17
th
Street, Suite 900
Denver, CO 80202
cdle_revenueassess_dowc@state.co.us
Page 2 of 2
( )
Phone Number
Email
Block #
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Payroll Statement Form (Colorado DORA)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 27 January 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document