Form Ic 4008 - Semi Annual Report Workers Compensation Premium Tax For The Period And Year
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1STATE OF IDAHO
SEMI-ANNUAL REPORT
INDUSTRIAL COMMISSION
WORKERS' COMPENSATION PREMIUM TAX
P.O. BOX 83720
FOR THE PERIOD AND YEAR ______________
BOISE. ID 83720-0041
JANUARY- JUNE
Street Address: 700 So. Clearwater Ln, Boise ID 83712
JULY - DECEMBER
INSURANCE COMPANY:
FEIN:
Contact Person:
Title:
Address:
City:
State:
Postal Code:
Phone:
Fax:
Gross Premiums Written
$
Less: Returned Premiums and
Premiums on Policies Not Taken
( - )
$
Net Premiums Written
( = ) $
0.00
Tax Rate 2.0%
( x )
$
0.00
.020
Tax Due (Net Premiums x Tax Rate)
$
75.00
*Minimum Tax Due = $75.00
AFFIDAVIT
, being first duly sworn, deposes and states that s/he is a
corporate officer, with the title of
, that this report is made
under the provisions of Section 72-524, Idaho code, and under penalty of perjury; that the foregoing
statement contains a full, true and accurate report of all workers' compensation premiums reportable on
business written on risk insured in the State of Idaho during the period set forth above.
(Signature of Corporate Officer)
State of
)
) ss.
County of
)
Subscribed and sworn to before me this
day of
,
Residing at
Notary Public
My Commission Expires
This report
is due
within 30 days after February 1 (in this office no later than March 3rd) for the last six months of the
preceding year, and within 30 days after July 1 (in this office no later than July 31st) for the first six
months of the current year.
LATE PAYMENT PENALTY- 10% of the original amount due times the number of ten-day
periods or portions thereof which have elapsed since March 3 or July 31 depending upon the
reporting period.
Submit the original completed report to the Industrial Commission
IC 4008, Revised 4/ 14
and retain a copy for your records.
If you have any questions, please contact one of the following Financial Specialists. If your company name begins with
A through I, please contact Therese Ryan at (208) 334-6095. If your company name begins with J through Z, please
contact Shelly Tudela at (208) 334-6026.
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