State of New Mexico - Taxation and Revenue Department
RPD-41055
Rev. 04/2004
WORKERS' COMPENSATION UNINSURED EMPLOYERS' FUND FEE REPORT
INSTRUCTIONS
PURPOSE: The Workers' Compensation Uninsured Employers' Fund provides medical and indemnity
benefits to injured workers whose employers fail to maintain workers' compensation coverage because of
fraud, misconduct or other failure to provide compensation payments. The Fund is maintained by the
recovery of costs from uninsured employers, supplemented by the uninsured employers' fund fee assessed
on insurance carriers and self-insurance programs.
LEGISLATIVE CHANGE: During the 2004 Legislative Session, the law authorizing the Workers' Compen-
sation Uninsured Employers' Fund was amended. Beginning July 1, 2004, the fund is maintained by the
collection of a $.30 increase in the quarterly workers' compensation fee assessed on employers who employ
persons covered by the Workers' Compensation Act and the uninsured employers' fees are no longer due.
The workers' compensation assessment fee is remitted with Form WC-1, Workers' Compensation Fee
Return. For information regarding the continued funding of the Workers' Compensation Uninsured Employ-
ers' Fund, review the Workers' Compensation Fee Instructions, RPD-41108. The Department's web site
is located at Click on Forms.
LINE INSTRUCTIONS: Round all money amounts to the nearest whole dollar. There is no space for
entering cents. For example, enter $10.49 as $10 and $10.50 as $11.
1) Paid losses: Paid losses are defined as the sum of medical and indemnity payments, exclusive of
attorney fees, allocated and unallocated loss adjusting expense, paid during the quarter for injuries
incurred after July 1, 2003 but paid before June 30, 2004, less recoveries by insurers, self-insurers, self-
insured groups or self-insured pools of governmental entities under subrogation rights. Payments made
by an employer or subject to reimbursement pursuant to a policy deductible or self-insured retention shall
be included in paid losses.
2) Uninsured employers' fund fee: Enter the product of line 1 multiplied by 0.5%.
If your report period falls between:
the rate is:
July 1, 2003 and June 30, 2004
0.5% (multiply line 1 by 0.005)
Insurers must file a report for each calendar quarter for the period of July 1, 2003 through June
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30, 2004, even if no fees are owed.
For paid losses incurred after June 30, 2004, you do not owe the fee and are not required to file
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this report. See LEGISLATIVE CHANGE above.