"Workers' Compensation Surcharge Quarterly Remittal Form" - 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.

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Workers’ Compensation Regulations Bureau
Insurance Compliance
Governor Steve Bullock
Commissioner Galen Hollenbaugh
Workers’ Compensation Surcharge Quarterly Remittal Form
INSTRUCTIONS: (REPRODUCE THIS FORM AS NEEDED)
Each Plan 2 Insurer and Plan 3, the State Fund, shall remit to the Department all earned premium surcharges collected during
a calendar quarter no later than 20 days following the end of the quarter.
Premium Surcharge rates effective July 1, 2018 (FY2019):
Administration Fund Surcharge Rate:
0.013644
(MCA 39-71-201)
Subsequent Injury Fund (SIF) PremiumSurcharge Rate:
0.003638
(MCA 39-71-915)
Occupational Safety & Health Administration (OSHA) FundSurcharge Rate:
0.009845
(MCA 50-71-128)
Insurer Name:
DLI:
Surcharge Contact Person:
Contact Person Phone#:
Surcharge Address:
Surcharge EmailAddress:
Premium Amount Assessed against:
Quarter Ending Date:
Administration Fund Surcharge:
SIF Surcharge:
OSHAFundSurcharge:
Total Remittance:
Do not submit payment under $5
Submit form only
Quarter Ending Date:
30-Sep
31-Dec
31-Mar
30-Jun
(7/1
9/30)
(10/1
12/31)
(1/1
3/31)
(4/1
6/30)
REMIT BY:
20-Oct
20-Jan
20-Apr
20-Jul
Penalty and Interest will be billed, separately, for payments received after remittance date.
Late Penalty for Administrative and Safety Fund Surcharges, each $500
Late Penalty for SIF Surcharge is $100
Interest rate of 12% per year will be applied to late paymentamounts
Remit Payment to:
Fiscal Support Bureau, PO Box 1728, Helena, MT 59624-1728
Fiscal Support Bureau, 1315 Lockey Ave, Helena, MT 59601
Contact Person Printed Name
Contact Person Signature
_
_
1805 Prospect
Phone (406) 444-6532
“Building a Stronger Montana”
P.O. Box 8011
Fax (406) 444-4140
Helena, MT 59601-8011
TTD (406) 444-5549
Workers’ Compensation Regulations Bureau
Insurance Compliance
Governor Steve Bullock
Commissioner Galen Hollenbaugh
Workers’ Compensation Surcharge Quarterly Remittal Form
INSTRUCTIONS: (REPRODUCE THIS FORM AS NEEDED)
Each Plan 2 Insurer and Plan 3, the State Fund, shall remit to the Department all earned premium surcharges collected during
a calendar quarter no later than 20 days following the end of the quarter.
Premium Surcharge rates effective July 1, 2018 (FY2019):
Administration Fund Surcharge Rate:
0.013644
(MCA 39-71-201)
Subsequent Injury Fund (SIF) PremiumSurcharge Rate:
0.003638
(MCA 39-71-915)
Occupational Safety & Health Administration (OSHA) FundSurcharge Rate:
0.009845
(MCA 50-71-128)
Insurer Name:
DLI:
Surcharge Contact Person:
Contact Person Phone#:
Surcharge Address:
Surcharge EmailAddress:
Premium Amount Assessed against:
Quarter Ending Date:
Administration Fund Surcharge:
SIF Surcharge:
OSHAFundSurcharge:
Total Remittance:
Do not submit payment under $5
Submit form only
Quarter Ending Date:
30-Sep
31-Dec
31-Mar
30-Jun
(7/1
9/30)
(10/1
12/31)
(1/1
3/31)
(4/1
6/30)
REMIT BY:
20-Oct
20-Jan
20-Apr
20-Jul
Penalty and Interest will be billed, separately, for payments received after remittance date.
Late Penalty for Administrative and Safety Fund Surcharges, each $500
Late Penalty for SIF Surcharge is $100
Interest rate of 12% per year will be applied to late paymentamounts
Remit Payment to:
Fiscal Support Bureau, PO Box 1728, Helena, MT 59624-1728
Fiscal Support Bureau, 1315 Lockey Ave, Helena, MT 59601
Contact Person Printed Name
Contact Person Signature
_
_
1805 Prospect
Phone (406) 444-6532
“Building a Stronger Montana”
P.O. Box 8011
Fax (406) 444-4140
Helena, MT 59601-8011
TTD (406) 444-5549
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