Fillable Surcharge Form COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT (Colorado DORA)

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Surcharge Form COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT (Colorado DORA)

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

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COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
DIVISION OF WORKERS’ COMPENSATION
Surcharge Form
for the period beginning July 1, 2020 and ending December 31, 2020
Do Not Alter this Address
Address Change or Correction
1
Total premium written on Colorado Workers’ Compensation Insurance policies with
deductibles less than $17,500, including excess coverage ……………………………………. $ ______________
2 Plus premium on deductible policies over $17,500, reported on a $17,500 deductible basis …...
$ ______________
3
Less total canceled or returned premiums ……………………………………………………….
$ ______________
4
Net premiums subject to surcharge ……………………………………………………………...
$ ______________
5
Net amount of Surcharge (1.45% of net premiums) …………………………………………….
$ ______________
(The assessment of 1.45% is the combined total of three separate surcharges: the Major Medical and Subsequent Injury
Funds at 0.10%; the Cash Fund at 1.35%; and the Premium Cost Containment Fund at 0.0 %.)
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 to before me this__________
day of ________________________, ___________
__________________________________________
FEIN
Block #
My commission expires_______________________
NAIC #
Mail to:
Division of Workers’ Compensation
633 17
th
Street, Suite 900
Denver, CO 80202
cdle_revenueassess_dowc@state.co.us
WC113 Rev 12/20
Page 1 of 1
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Surcharge Form COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT (Colorado DORA)

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Completed 27 January 2021

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