Form WC-10-A "Workers' Compensation Mitf Assessment Report (Individual Self-insured Employers) (Assessment Period 10-1-19 to 12-31-19)" - Oklahoma

What Is Form WC-10-A?

This is a legal form that was released by the Oklahoma Tax Commission - a government authority operating within Oklahoma. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2019;
  • The latest edition provided by the Oklahoma Tax Commission;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form WC-10-A by clicking the link below or browse more documents and templates provided by the Oklahoma Tax Commission.

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Download Form WC-10-A "Workers' Compensation Mitf Assessment Report (Individual Self-insured Employers) (Assessment Period 10-1-19 to 12-31-19)" - Oklahoma

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WC-10-A
Revised 7-2019
Workers’ Compensation
ASI
-Office Use Only-
Multiple Injury Trust Fund (MITF)
Assessment Report
Use For Assessment Period 10-1-19 thru 12-31-19
(Individual Self-Insured Employers)
for quarter ending _________________
Amended Report: Place an “X” in this box if this is an amended WC-10-A:
Remit the MITF assessment, together with this report, to the Oklahoma Tax Commission for this calendar quarter
by the 15th day of the following month. Failure to timely remit, or to notify the Workers’ Compensation Commis-
sion of the payment within 10 days thereof, may result in administrative penalties, including but not limited to, a
fine payable to the Commission equal to the greater of $500.00 or 1% of the unpaid amount.
Federal Employer Identification Number ________________________________________________
Name of Self-Insured Employer ________________________________________________________
Own Risk Permit Number _____________________________________________________________
Street Address _____________________________________________________________________
City, State and Zip ___________________________________________________________________
Email Address of Contact Person ______________________________________________________
I .
Actual paid losses (Excluding loss
adjustment expenses and reserves) this quarter ................................
2.
Multiple Injury Trust Fund assessment (7% of line 1) .........................
The undersigned hereby certifies, under penalty of perjury, that he/she executed this report of his/her free and
voluntary will and as the duly authorized representative of the taxpayer named above, that the information and
amounts herein contained reflect a true, accurate and complete statement.
Signed ___________________________________________________
Name of Self-Insured Employer
By _______________________________________________________
Name, Title and Phone Number
Mail your report and remittance to:
Oklahoma Tax Commission
Account Maintenance Division
Special Taxes
2501 North Lincoln Blvd
Oklahoma City, OK 73194-0004
Send notice of remittance within 10 days thereof to:
Workers’ Compensation Commission
1915 N. Stiles Avenue, Room 231
Oklahoma City, OK 73105-4908
For additional information, see page 2.
If you have questions, please call (405) 522-8007.
WC-10-A
Revised 7-2019
Workers’ Compensation
ASI
-Office Use Only-
Multiple Injury Trust Fund (MITF)
Assessment Report
Use For Assessment Period 10-1-19 thru 12-31-19
(Individual Self-Insured Employers)
for quarter ending _________________
Amended Report: Place an “X” in this box if this is an amended WC-10-A:
Remit the MITF assessment, together with this report, to the Oklahoma Tax Commission for this calendar quarter
by the 15th day of the following month. Failure to timely remit, or to notify the Workers’ Compensation Commis-
sion of the payment within 10 days thereof, may result in administrative penalties, including but not limited to, a
fine payable to the Commission equal to the greater of $500.00 or 1% of the unpaid amount.
Federal Employer Identification Number ________________________________________________
Name of Self-Insured Employer ________________________________________________________
Own Risk Permit Number _____________________________________________________________
Street Address _____________________________________________________________________
City, State and Zip ___________________________________________________________________
Email Address of Contact Person ______________________________________________________
I .
Actual paid losses (Excluding loss
adjustment expenses and reserves) this quarter ................................
2.
Multiple Injury Trust Fund assessment (7% of line 1) .........................
The undersigned hereby certifies, under penalty of perjury, that he/she executed this report of his/her free and
voluntary will and as the duly authorized representative of the taxpayer named above, that the information and
amounts herein contained reflect a true, accurate and complete statement.
Signed ___________________________________________________
Name of Self-Insured Employer
By _______________________________________________________
Name, Title and Phone Number
Mail your report and remittance to:
Oklahoma Tax Commission
Account Maintenance Division
Special Taxes
2501 North Lincoln Blvd
Oklahoma City, OK 73194-0004
Send notice of remittance within 10 days thereof to:
Workers’ Compensation Commission
1915 N. Stiles Avenue, Room 231
Oklahoma City, OK 73105-4908
For additional information, see page 2.
If you have questions, please call (405) 522-8007.
Form WC-10A
Multiple Injury Trust Fund Assessment
Page 2
Insurance carriers writing workers’ compensation insurance in Oklahoma, and self-insured employers, including
group self-insurance associations, shall pay quarterly to the Oklahoma Tax Commission an assessment for
the Multiple Injury Trust Fund in an amount not exceeding seven percent (7%) of gross direct written premium (for
workers’ compensation insurers), normal premium (for group self-insurance associations), and actual paid losses
(for individual self-insured employers). The assessment rate is determined annually by the Workers’ Compensation
Commission pursuant to a statutory formula. Notice of the rate is provided to payors by May 1 of each year. The
rate is for the four-quarter assessment period of July 1 to June 30. Uninsured employers (those who do not secure
their workers’ compensation obligations) are assessed five percent (5%) of their total compensation paid for
permanent disability and death awards.
Assessments are due on the 15th day of the month following the end of the calendar quarter and are based
on the payor’s premium or losses, as applicable, during the quarter. Failure to make assessment payments, or
to timely notify that payment was made, may result in administrative penalties, including but not limited to, the
greater of $500 or 1% of the unpaid amount. Notice of each payment must be given to the Oklahoma Insurance
Commissioner if the payor is an insurance carrier, or to the Workers’ Compensation Commission if the payor is an
individual or group self-insurer.
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