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MANUAL OF INSURANCE PROCEDURES Form 3 ­ Monthly Payroll Report

Monthly On-Site Payroll Report - Form 3 This form must be completed each month by the Contractor and its Subcontractors on the Project Site for each contract awarded. The completed form is to be faxed or emailed to the OCIP Administrator within two weeks following the end of the payroll-reporting period. The Contractor will be responsible to require the submission of this form by their subcontractors. COMPLETION INSTRUCTIONS 1. 2. Contractor Name: Contract #: Your firm's name. Contract or Specification number for this project. Indicate location number, if applicable. Fill in applicable payroll period. Indicate whom your contract is with. Can be obtained from your Workers' Compensation policy or your insurance agent, or from the information you completed (Form 1) List manhours and payroll (all time including straight time, overtime, and double time) for each class code. List one cumulative monthly payroll figure for all employees who fall under each class code.

3. 4. 5.

Reporting Period: Contract With: Workers' Compensation Classification Code: Manhours and Payroll*: a) Hourly b) Salaried

6.

7.

Sign and Date form.

*Payroll is based on straight time plus overtime and double time.

2009/Children's Hospital OCIP Manual Final

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MANUAL OF INSURANCE PROCEDURES Form 3 ­ Monthly Payroll Report

WORKERS' COMPENSATION ON-SITE PAYROLL REPORT

CONTRACTOR NAME: PROJECT NAME: YOUR CONTRACT #: REPORTING PERIOD FROM: CONTRACT WITH: LOCATION #: TO:

**NOTE: PAYROLL CONSTITUTES ALL WAGES AND INCLUDES BONUSES, VACATION PAY, HOLIDAY PAY, SICK PAY, 401K WAGES AND ANY GOODS OR SERVICES RECEIVED BY EMPLOYEES AS PAY OR SUBSTITUTE FOR PAY. A. Hourly Paid Employees TOTAL MONTHLY PAYROLL

WC CLASS CODE

DESCRIPTION

HOURS

STRAIGHT TIME ($)

OVER TIME ($)

DOUBLE TIME ($)

B.

Salaried Employees TOTAL MONTHLY PAYROLL

WC CLASS CODE

DESCRIPTION

AVERAGE HOURS

LOCATION OF PAYROLL RECORDS: NAME: TELEPHONE: EMAIL: FAX:

I hereby certify that the payroll figures and information contained above are true and complete as shown for the period of this report. DATE: SIGNATURE: NAME: TITLE:

Fax or email this form to Ashley McAlpine: Fax No. (205) 581-9320 Email: [email protected]

2009/Children's Hospital OCIP Manual Final

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