"Montana Workers' Compensation Surcharge Quarterly Remittal Form" - Montana

Montana Workers' Compensation Surcharge Quarterly Remittal Form is a legal document that was released by the Montana Department of Labor and Industry - a government authority operating within Montana.

Form Details:

  • Released on August 20, 2021;
  • The latest edition currently provided by the Montana Department of Labor and Industry;
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Montana Workers’ Compensation Surcharge Quarterly Remittal Form FY 2022
INSTRUCTIONS: (REPRODUCE THIS FORM AS NEEDED)
Instructions can be found on page 2 of this report and on our website at
Surcharge Forms &
Instructions.
Premium Surcharge rates effective July 1, 2021 (FY2022).
Administration Fund Surcharge Rate (MCA 39-71-201) ……………………………………………………......0.021020
Occupational Safety & Health Administration (OSHA) Fund Surcharge Rate (MCA 50-71-128) ……...……. 0.007991
Subsequent Injury Fund (SIF) Premium Surcharge Rate (MCA 39-71-915) ……………………………..…… 0.005410
Insurer Name: _____________________________________________
DLI: ___________
Quarter Ending Date: ___________________
NAIC: _______________
0.00
1. Direct Premiums Earned (actual)……………………………….……………… $________________________
2. Surcharge Due at current rates (If line 1 is negative enter $0 on line 2d):
0.000
a. Admin Surcharge Rate (line 1 times 0.021020) … $__________________
0.000
b. OSHA Surcharge Rate (line 1 times 0.007991) … $__________________
0.000
c. SIF Surcharge Rate (line 1 times 0.005410) ……. $__________________
0.00
d. Total Gross Surcharge Remittance (Sum of 2a, 2b, 2c) ….……………. $___________________
0.00
3. Adjustments for prior period surcharge over-collections or overpayments, if applicable…... $______________
(See Instructions. Only apply if 2d >= line 3. Attach supporting documentation. Additional information found on
page 2 of this form.)
0.00
4. Total Net Remittance (line 2d minus line 3) ……………..…………… $___________________
**Do not submit payment under $5 –Submit form only
**$0.00 forms can be emailed to
WCRegBureauQER@mt.gov
Mail form with payment to:
Department of Labor & Industry
Mailing:
P.O. Box 1728, Helena MT 59624-1728
Overnight:
1315 Lockey Ave, Helena MT 59601
Surcharge Contact Person Printed Name: _______________________________
Surcharge Contact Person Signature: __________________________________
Surcharge Contact Person Phone#: __________________________ Surcharge Email Address: _____________________
Surcharge Address: ______________________________________________________________
Montana Workers’ Compensation Surcharge Quarterly Remittal Form FY 2022
INSTRUCTIONS: (REPRODUCE THIS FORM AS NEEDED)
Instructions can be found on page 2 of this report and on our website at
Surcharge Forms &
Instructions.
Premium Surcharge rates effective July 1, 2021 (FY2022).
Administration Fund Surcharge Rate (MCA 39-71-201) ……………………………………………………......0.021020
Occupational Safety & Health Administration (OSHA) Fund Surcharge Rate (MCA 50-71-128) ……...……. 0.007991
Subsequent Injury Fund (SIF) Premium Surcharge Rate (MCA 39-71-915) ……………………………..…… 0.005410
Insurer Name: _____________________________________________
DLI: ___________
Quarter Ending Date: ___________________
NAIC: _______________
0.00
1. Direct Premiums Earned (actual)……………………………….……………… $________________________
2. Surcharge Due at current rates (If line 1 is negative enter $0 on line 2d):
0.000
a. Admin Surcharge Rate (line 1 times 0.021020) … $__________________
0.000
b. OSHA Surcharge Rate (line 1 times 0.007991) … $__________________
0.000
c. SIF Surcharge Rate (line 1 times 0.005410) ……. $__________________
0.00
d. Total Gross Surcharge Remittance (Sum of 2a, 2b, 2c) ….……………. $___________________
0.00
3. Adjustments for prior period surcharge over-collections or overpayments, if applicable…... $______________
(See Instructions. Only apply if 2d >= line 3. Attach supporting documentation. Additional information found on
page 2 of this form.)
0.00
4. Total Net Remittance (line 2d minus line 3) ……………..…………… $___________________
**Do not submit payment under $5 –Submit form only
**$0.00 forms can be emailed to
WCRegBureauQER@mt.gov
Mail form with payment to:
Department of Labor & Industry
Mailing:
P.O. Box 1728, Helena MT 59624-1728
Overnight:
1315 Lockey Ave, Helena MT 59601
Surcharge Contact Person Printed Name: _______________________________
Surcharge Contact Person Signature: __________________________________
Surcharge Contact Person Phone#: __________________________ Surcharge Email Address: _____________________
Surcharge Address: ______________________________________________________________
2
Montana Workers’ Compensation Surcharge Remittance General Instructions
MCA 39-71-201
ARM 24.29.956
General Instructions:
The premium surcharge must be calculated and collected by each Plan 2 Insurer and by Plan 3, the State Fund, from each employer
that it insures. The premium surcharge must be paid whenever the employer pays a premium to the insurer, and the insurer shall pay
the Department all the money collected as premium surcharge within 20 days of the end of the calendar quarter in which it was
collected.
Each Plan 2 and the Plan 3 Insurer are responsible for correctly calculating the amount of the authorized premium surcharge to be
collected from an employer. Over-collections or overpayments may be addressed in the following manner:
1. Over-Collections from a Policyholder by an Insurer
a. Any over-collection of a surcharge from a policyholder by the insurer may be refunded by the insurer or applied to
premium or future surcharge payments due from the policyholder to the insurer. An accounting of the payment
shall be provided by the insurer to the policyholder.
2. Overpayments made from an Insurer to the Department
a. If a surcharge remittance from an insurer to the Department is later determined to include an overpayment, the
insurer may deduct the amount overpaid from the next surcharge remittance due from the insurer to the
Department. The insurer shall maintain records documenting any surcharge amounts refunded to its policyholders.
Detailed Form Instructions:
1. Fill out the Insurer’s Name, DLI number (assigned to the insurer by the Department), Quarter Ending Date, and NAIC code.
2. Line 1. Direct Premiums Earned- As reported in column 2 of the Annual Statement/Exhibit of Premiums and Losses
(Statutory Page 14) submitted to the Montana Insurance Commissioner. Quarterly submissions should reconcile to the
amount reported to the Insurance Commissioner at year-end. Report actual number.
3. Line 2. Surcharge Due at current rates- Calculate line 1 by each applicable rate shown in 2a, 2b, 2c, and show total of 2a,
2b, 2c on line 2d. If Direct Premiums Earned is negative, report a $0.00 and email to
WCRegBureauQER@mt.gov.
4. Line 3. Adjustments for prior period surcharge over-collections or overpayments, if applicable- The sum of over-
collections or overpayments being deducted from the surcharge remittance total sent to the Department. Attach supporting
documentation. Only apply adjustments if the 2d is greater than or equal to line 3, otherwise carry forward to the next
quarter in which the surcharge remittance is greater than or equal to line 3.
5. Line 4. Total Net Remittance- Total Gross Surcharge Remittance from line 2d minus adjustments from line 3.
6. Fill out the bottom of the form’s contact information and remit to the highlighted address on the form or
if you have a $0.00 report.
WCRegBureauQER@mt.gov
FY 22 Surcharge Form 08/20/21 (AM)
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