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QUARTERLY UNIFIED EMPLOYER ASSESSMENT SURCHARGE
Workers' Compensation Insurers Remittance Form
State of New York - Workers' Compensation Board
GA-2 (2025)
Insurer Information:
Insurers who are part of a larger insurer group must
complete and submit a separate
Form GA-2
for each insurer
in the group by WCB Identification Number (W Number).
However, a single aggregated payment may be made for the
insurer group. Insurers submitting an aggregated payment must
complete the
Quarterly Unified Employer Assessments
Surcharge Workers' Compensation Insurers Remittance Form -
Insurer Group Addendum (Form GA-2.1)
1.
*
WCB Identification Number (W Number):
2.
*
FEIN:
3.
*
Insurer Name:
4.
*
Mailing Address
Number and Street:
City:
State:
Select State
New York
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Dist of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
5.
*
NAIC Company Number:
6.
*
NAIC Group Number:
Certification:
By submitting this form via email, the sender certifies that the information presented herein, including all applicable
addendums, has been examined and is a true, correct, and complete report made in good faith.
*
Name
*
Title
*
Email Address
*
Confirm Email Address
*
Phone - ext.
Date (automatically filled)
In
accordance
with
WCL
Section
151,
the
Chair
may
conduct
periodic
audits
of
any
insurer
on
any
information
relevant
to
the
payment
or
calculations
of
assessments.
If
an
insurer
underpays
an
assessment
as
a
result
of
inaccurate
reporting,
the
insurer
shall
pay
the
full
amount
of
the
underpaid
assessment
along
with
interest
at
the
rate
of
9%
per
annum.
Further,
in
the
event
that
it
is
determined
that
the
payer
knew
or
should
have
known
that
the
reported
information
was
inaccurate,
an
additional
penalty
of
up
to
20%
may
be
imposed.
Any
insurer
that
knowingly
makes
a
material
misrepresentation of information required for the purposes of assessments shall be guilty of a class E felony.
Please refer to
Instructions for Completing Quarterly Unified Employer Assessment Surcharge Workers' Compensation
Insurers Remittance Form (Form GA-2)
GA-2 Instructions
*
Indicates a required field
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