NORTH CENTRAL WASHINGTON WORKERS' …



NORTH CENTRAL WASHINGTON WORKERS' COMPENSATION TRUST

P.O. Box 1847

Wenatchee, WA 98807-1847

TRANSMITTAL OF MONTHLY PREMIUM

(Submit with Each Month's Payment)

For the   School District for the Month of , 20 .

| |Total |Total |Industrial Insurance |

| |School |School |Medical Aid, and |

| |District |District |Supplemental Pension |

|Worker |Salary |Worker |Rate and Premium |

|Classification |Dollars |Hours |Rate/Hour |Premium |

|613 | | | | |

|614 | | | | |

|724 "Preferred Worker" Program | | | | |

|Volunteers | | | | |

|Others (List) | | | | |

|Totals (Be sure to fill in totals) | | | | |

|INSTRUCTIONS: | |

|1. Enter the total worker hours and salary dollars by worker classification above. Multiply| |

|worker hours by the appropriate rate to compute the premium. | |

|2. If the premium due is $5.00 or more than the data processing system warrant, then a |Total Remitted |

|revolving fund check should be prepared for the difference. |With This |

|3. Payment is due by the fifth day of the following month (i.e., the premium for February is|Transmittal |

|due by or before March 5). | |

|4. Sports officials registered with the Washington Officials Association should not be | |

|reported on this transmittal. |No. of Employees |

|5. Reminder: Employees under the "Preferred Worker" program (Class Code 724) must be | |

|reclassified as type 613 or 614 three years after their hire date. | |

| |(Make Warrant Payable to: NCWWCT) |

| | |

| |I Hereby Certify the Above is True and Accurate. |

| | |

| |Signed: |

| | |

| |Title: |

| | |

| |Date: |

G:\CooperativeBudgetsAndManagement\NCWWCT\Correspondence\NCWWCT Transmittal Form.doc

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