Free SI-5 - Florida

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 CLASS RATE PER $100

OCCUPATION

PAYROLL*

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)