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Workers' Compensation
P A Y - A S - Y O U - G O - R E P O R T

This report is designed to help you reduce paperwork and record keeping. To complete:

  1. Enter payroll.
  2. Multiply by rate to determine earned premium by class.
  3. Total for earned premium. (multiply by experience mod and other factors if needed.
  4. Attach check for total and return with one copy within 10 days.
Insurance Co.:
Policy #:
Report Period: to
Named Insured:
Email Address:

PLEASE ROUND ALL PAYROLL AND PREMIUMS TO THE NEAREST WHOLE DOLLAR

CLASSIFICATION CODE PAYROLL RATE PREMIUM
Earned Premium:
**Monthly Maximum Each Officer:
**Monthly Minimum Each Officer:

The above rates are net and are inclusive of all premium modifiers and rating credits. This includes the 2001 Experience Modification of:

GOLDEN PACIFIC INSURANCE SERVICES
181 W. HUNTIINGTION DR., SUITE 200
MONROVIA, CA 91016

 

Insurance Integrity and Personal Service
GOLDEN PACIFIC INSURANCE SERVICES, INC.
License# 0773850

181 West Huntington Dr., Suite 200, Monrovia, CA 91016
Mailing Address: P.O. Box 7045, Pasadena, CA 91109-7045
(626) 275-3000 voice, (626) 275-0130 fax

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