Form Si-5 - Self-Insurance Payroll Report

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DIVISION OF WORKERS' COMPENSATION
BUREAU OF MONITORING AND AUDIT
SELF-INSURANCE SECTION
SELF-INSURER PAYROLL REPORT
EMPLOYER NAME AND ADDRESS:
EMPLOYER NO.
PERIOD COVERED
EXPERIENCE MODIFICATION
*Includes the entire remuneration,
whether paid in money or a substitute
for money, for services rendered by
employee.
AMOUNT OF PAYROLL BY OCCUPATIONAL CLASSIFICATIONS
MANUAL
RATE PER
OCCUPATION
CLASS
PAYROLL*
$100
PREMIUM
Please return form to : SELF-INSURANCE SECTION
200 East Gaines Street
Tallahassee, Florida 32399-4224
ASSESSMENT COMPUTATIONS WILL BE SENT WITH BILLING
Form SI-5 (9/96)

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