Quarterly Premium Surcharge Payment Form

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QUARTERLY PREMIUM SURCHARGE PAYMENT FORM
INSURER NAME:
__________________________________________________________________
ADDRESS:
STATE:
ZIP CODE:
__________________
INSURER NCCI NUMBER: ___________________________________
DATE OF REPORT
QUARTER ENDING DATE
DOLLAR AMOUNT SUBMITTED
___________________________________________________________________________________
CERTIFYING OFFICIAL (TYPE)
___________________________________________________________________________________
CERTIFYING OFFICIAL (SIGNATURE)
___________________________________________________________________________________
_ TITLE
__________________________________________
____ TELEPHONE NUMBER
PLEASE MAIL THE FORM AND CHECK TO:
PLEASE SUBMIT A COPY OF THE FORM TO:
D. C. Department of Employment Services
Office of the Chief Financial Officer
D. C. Department of Employment Services
500 C Street, N. W., Suite 637-B
Office of Workers= Compensation
Washington, D.C. 20001
Insurance Unit
(202)-724-7150
P.O. Box 56098
Washington, D.C. 20011
Fax Number: (202) 541-3595

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