NORTH CENTRAL WASHINGTON WORKERS' COMPENSATION TRUST
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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