Form Chswc-1 - Workers' Occupational Safety And Health Education Fund Fee Report Form - Department Of Industrial Relations
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1State of California
Department of Industrial Relations
Commission on Health and Safety and Workers’ Compensation
WORKERS’ OCCUPATIONAL SAFETY AND HEALTH
EDUCATION FUND FEE REPORT FORM
LABOR CODE SECTION 6354.7 REQUIRES ALL WORKERS’ COMPENSATION INSURERS TO FUND THE
“WORKERS’ OCCUPATIONAL SAFETY AND HEALTH EDUCATION FUND “BY PAYING AN ANNUAL FEE OF
THE GREATER OF $100 OR A PERCENTAGE OF THEIR PAID WORKERS’ COMPENSATION INDEMNITY AS
REPORTED FOR THE PRIOR CALENDAR YEAR ON THE “CALL FOR CALIFORNIA WORKERS’
COMPENSATION EXPERIENCE” FILED WITH THE WORKERS’ COMPENSATION INSURANCE RATING
BUREAU (WCIRB) OF CALIFORNIA.
PLEASE COMPLETE AND SUBMIT THIS REPORT FORM WITH THE REQUIRED FEES AND ATTACHMENTS
TO THE ADDRESS LISTED BELOW. PAYMENT IS DUE ON OR BEFORE APRIL 1 OF THIS YEAR.
1. NAME OF INSURER (S):
List all insurer names used to write workers’ compensation insurance in California. For each insurer
listed, attach a copy of each insurer’s Certificate of Authority, issued by the California Department of
Insurance to write workers’ compensation insurance. (Attach additional if needed)
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
2. COMPANY OFFICER:
Name the person with the authority to establish the program to provide loss control consultation services
in California and authorize the payment to fees into the Fund.
Signature of
Date:
Company Officer:
Printed Name of Officer:
Title:
(The address below will be only address used for all future correspondence from this office.)
Name of Company
Address:
Phone Number:
Fax Number:
E-mail Address:
Indicate the total amount of Paid Indemnity as reported for the prior calendar year on the “Call for
3. FEE CALCULATION:
California Workers’ Compensation Experience” filed with the Workers’ Compensation Insurance Rating
Bureau of California (WCIRB) for each insurer listed above, and calculate the fees due.
(Include a copy of the 2016 Calendar Year “Call” for each insurer listed on this application.)
Calendar Year 2016
Pay this amount
Enter Total
or $100, which-
Paid Indemnity
$_______________________ X
.000286
=
Fee Here: $___________________ ever is greater.*
[Example - $43,060,531.00(PI) x .000286 = $12,315.31 (Fee)]
*Either: (1) Make payment online
(2) Attach a check payable to Workers’ Occupational Safety and Health Education Fund or WOSHEF.
OR:
Please mail this completed report with the “Call(s)”, the Certificate(s) of Authority, and fees, if
:
4. SUBMISSION
applicable to the following address before 04/01/2017:
Commission on Health and Safety and Workers’ Compensation
Attention: WOSHEF
th
1515 Clay Street, 17
Floor, Oakland, CA 94612
If you have questions regarding this fee or report process, call (510) 622-3959 or e-mail us at WOSHEF@dir.ca.gov
CHSWC-1 (Rev. 1/17)
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