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QUARTERLY UNIFIED EMPLOYER ASSESSMENT SURCHARGE
Workers' Compensation Insurers Remittance Form
Insurer Group Addendum
State of New York - Workers' Compensation Board
GA-2.1 (2025)
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GA-2.1 Instructions
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Insurer Group Name:
Reporting Period:
Calendar Year:
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Quarter Ending:
Select
Q1
Q2
Q3
Q4
Insurer Group Information:
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WCB ID Number
(W Number)
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FEIN
NAIC Company
Number
*
Insurer Name
*
Total Surcharge
Due
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Total Surcharge Due (equals total of amount shown in Column (15) of the
Quarterly Unified Assessment Surcharge
Workers' Compensation Insurers Remittance Form (Form GA-2)
for all insurers submitting an aggregate payment)
Certification:
By submitting this form, 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.
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Name
*
Title
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Email Address
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Confirm Email Address
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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.
If you do not receive a confirmation email with a PDF copy of the quarterly form, then the Board did not receive your form. Please try to attach a saved version of this
form to an email to
Assessments@wcb.ny.gov
. If you still do not receive an email confirmation, please contact the Board by sending an email to
WCBFinanceOffice@wcb.ny.gov
.
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