Get Wc-10-a-07

The WC-10-A-07 form, also known as the Multiple Injury Trust Fund Assessment Report, is essential for individual self-insured employers to report their assessments accurately. This guide will provide you with clear, step-by-step instructions for filling out the form online, ensuring you comply with the necessary regulations.

Follow the steps to complete the WC-10-A-07 form online.

1. Press the ‘Get Form’ button to obtain the form and open it in your chosen online editor.
2. Enter the federal employer identification number in the designated field. This number is required to uniquely identify your organization.
3. Fill in the name of the self-insured employer. Ensure the name matches the official records.
4. Input the own risk permit number. This number is critical for confirming your ability to self-insure.
5. Provide the street address, city, state, and zip code of the self-insured employer in the respective fields.
6. Include the email address of the contact person for correspondence regarding this report.
7. In the section for actual paid losses, report the total paid losses for the quarter. Ensure that this number does not include loss adjustment expenses and reserves.
8. Calculate the Multiple Injury Trust Fund assessment, which is 2.5% of the amount reported in the previous step and enter it in the designated field.
9. Read the certification statement carefully, then ensure that it is signed by the authorized representative of the self-insured employer. Include their name, title, and phone number.
10. After reviewing all entries for accuracy, save your changes, and prepare to print or share the form as needed. Ensure all filing requirements are met before submission.

Complete the WC-10-A-07 form online to ensure compliance and timely submission of your assessment!