The Quarterly Unified Employer Assessment Municipal Self-Insurers Remittance Form (GA-4) is a crucial document required by the State of New York for all active municipal self-insured employers. This form must be completed each quarter and submitted within thirty days following the end of the quarter, ensuring compliance with workers' compensation regulations. To ensure your reporting is accurate and timely, consider filling out the form by clicking the button below.
The Quarterly Unified Employer Assessment Municipal Self-Insurers Remittance Form, commonly referred to as the GA-4, serves as a critical reporting tool for municipal self-insured employers in New York. This form must be completed and submitted every quarter, ensuring compliance with state regulations regarding workers' compensation. It collects essential information, including the WCB Identification Number, the legal name of the self-insured employer, and the Federal Employer Identification Number (FEIN). The GA-4 also requires employers to detail their total payroll, distinguishing between school districts and other municipal employees, which facilitates the calculation of the assessment based on established loss costs. Employers must accurately report their payroll figures to determine the total assessment due, which is calculated as a percentage of the total loss cost. Additionally, the form includes a certification section where the undersigned attests to the accuracy of the provided information, emphasizing the importance of transparency and accountability in the reporting process. By adhering to these guidelines, municipal self-insurers can ensure their compliance and maintain their self-insured status.
QUARTERLY UNIFIED EMPLOYER ASSESSMENT
Municipal Self-Insurers Remittance Form
State of New York - Workers' Compensation Board
A. Municipal Self-Insurer Information
1.
WCB Identification
2. Name of Municipal
Number:
Self-Insured Employer:
"W Number"
Note: Additional employers covered under the W number shown must be reported on the
Quarterly Unified Employer Assessment Municipal Self-Insurers Remittance Form - Payroll by
3.
FEIN:
FEIN Addendum (GA-4.1)
4.
Mailing Address:
Number and Street
City
State
Zip Code
B.Reporting Period
1.Calendar Year:
2.Quarter Ending:
C.Basis for Assessment
(5) Total Loss
(4) Loss Cost Per
Cost
(3) Quarterly
(1) Payroll Class
Hundred Dollars
(3) x (4) divided
Code
(2) Description
Payroll Dollars
of Payroll
by $100
Various
School District - All Employees
$0.50
All Other Municipal Employees
$1.80
(6) Subtotal Payroll
$0
(7) Excluded Payroll Not Subject to Assessment (if applicable)
(8) Total Payroll = (6) + (7)
(9) Total Loss Cost
(10) Assessment Rate
13.8%
(11) Total Assessment Due
D. Certification
The undersigned 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.
Signature
Title
Type or Print Name
Date
Phone Number
-Mail
GA-4
(Instructions on Reverse Side)
Instructions for Completing Quarterly Unified Employer Assessment
General Instructions
1.The Quarterly Unified Employer Assessment Municipal Self-Insurers Remittance Form (GA-4) must be completed each quarter on a calendar year basis by every active municipal self-insured employer and submitted, with payment, within thirty days of the end of the quarter.
2.Additional municipal employers covered under the W number shown must be reported on the Quarterly Unified Employer Assessment Municipal Self- Insurers Remittance Form - Payroll by FEIN Addendum (GA-4.1) such as those covered under a county plan or municipal group.
3.Questions about the form or process should be directed to [email protected].
4.Checks are to be made payable to the Chair, NYS Workers' Compensation Board.
5.To ensure the proper application of payment please include W Number and applicable quarter on check.
6.This report and corresponding payment, along with applicable addendum, must be submitted quarterly by every municipal employer actively self- insured for workers' compensation. Employers that discontinued their self-insurance program (i.e., inactive self-insurers) and employers actively or inactively self-insured for disability benefits do not have to submit.
Submit completed form via e-mail to:
[email protected]
and mail check to address below
Or mail completed form and check to:
New York State Workers’ Compensation Board
328 State Street
Finance Unit, Room 331
Schenectady, NY 12305-2318
Municipal Self-Insurer Information
1.The WCB Identification Number or "W Number" as assigned to the municipal self-insurer when approved to self-insure.
2.The Name of the Municipal Self-Insured Employer must be the full legal name of the employer approved to self-insure.
3.The FEIN, or Federal Employer Identification Number, must be reported for the municipal self-insurer. Additional municipal employers covered under the W number shown must be reported on the Quarterly Unified Employer Assessment Municipal Self-Insurers Remittance Form - Payroll by FEIN Addendum (GA-4.1) such as those covered under a county plan or municipal group.
4.The full mailing address of the municipal self-insurer to be used for all correspondence related to the unified assessment must be provided.
Basis for Assessment
1.A blended rate for municipal payroll will be used and there is no need to breakout by class.
2.Payroll must be broken out between employers which are school districts and all other municipal employers.
3.Total quarterly payroll associated with either the school district and/or all other types of municipal self-insurers.
4.The loss cost per hundred dollars of payroll for municipal employers and school districts is set annually by the Chair. The rates are shown on the Quarterly Unified Employer Assessment Municipal Self-Insurers Remittance Form (GA-4) .
5.The total loss cost is determined by multiplying the payroll by the loss cost shown and dividing by $100.
6.Subtotal of payroll reported on the Quarterly Unified Employer Assessment Municipal Self-Insurers Remittance Form (GA-4) .
7.Excluded payroll not subject to assessment.
8.With limited exception, total payroll should agree with that reported on the Quarterly Combined Withholding, Wage Reporting and Unemployment
Insurance Return (NYS-45) ; specifically, Part Line 1 Total Remuneration Paid This Quarter. If total quarterly payroll does not agree with NYS-45,
please provide reconciliation. No payroll caps are to be applied.
9.
Equal to the sum of all of the loss cost by payroll class shown.
10.
The assessment rate for the rating period established by the Chair pursuant to WCL Section 151. This can be found on the WCB's website --
www.wcb.ny.gov.
11.
The total assessment due is equal to the total loss cost multipled by the assessment rate.
Certification
In accordance with WCL Section 151 the Chair may conduct periodic audits of any self-insurer on any information relevant to the payment or calculation of assessments. If a self-insurer underpays an assessment as a result of inaccurate reporting the self-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. The failure of a self-insurer to timely remit assessment payments and required reports shall constitute good cause for revocation of self-insured status. An employer that knowingly makes a material misrepresentation of information required for the purposes of assessments shall be guilty of a class E felony.
GA-4 (Reverse)
Payroll by FEIN Addendum
2. Name of
1. WCB Identification
Municipal Self-
Insured Employer:
C.Municipal Employers Covered Under the W Number Shown Above
(4) Excluded
Payroll (if
(1) FEIN
(2) Municipal Self-Insured Employer Name
Payroll
applicable)
(5) Subtotal Payroll
(6) Subtotal Excluded Payroll (if applicable)
(7) Total Payroll = (5) + (6)
GA-4.1(Instructions on Reverse)
2.The Quarterly Unified Employer Assessment Municipal Self-Insurers Remittance Form - Payroll by FEIN Addendum(GA-4.1) is required when more than one employer is approved to self-insure on a consolidated basis under the W number shown.
3.The payroll by class code reported on the Quarterly Unified Employer Assessment Municipal Self-Insurers Remittance Form (GA-4) must include all employers listed here.
4.Questions about the form or process should be directed to [email protected].
5.This addendum, if applicable, must be sent quarterly with the Quarterly Unified Employer Assessment Municipal Self-Insurers Remittance Form (GA-4) .
1.The WCB Identification Number or "W number" as assigned to the municipal self-insurer when approved to self-insure.
2.The Name of the Municipal Self-Insured employer must be the full legal name of the municipal employer, county plan or group approved to self-insure.
Municipal Employers Covered Under the W Number
1.The FEIN, or Federal Employer Identification Number, must be reported for the municipal self-insurer and all other employers approved to self-insure on a consolidated basis under the W number assigned (including members of a group or county plan).
2.The municipal self-insured employer name should be the full legal name of the employer approved to self-insure.
3.Total quarterly payroll associated with the FEIN number.
4.Excluded payroll not subject to assessment.
5.Subtotal of payroll subject to assessment of the Quarterly Unified Employer Assessment Municipal Self-Insurers Remittance Form - Payroll by FEIN
6.Subtotal of excluded payroll not subject to the assessment of the Quarterly Unified Employer Assessment Municipal Self-Insurers Remittance Form - Payroll by FEIN Addendum (GA-4.1) .
7.Total payroll and excluded payroll if applicable. With limited exception, total payroll should agree with that reported on the Quarterly Combined
Withholding, Wage Reporting and Unemployment Insurance Return (NYS-45) ; specifically, Part Line 1 Total Remuneration Paid This Quarter. If total quarterly payroll does not agree with NYS-45, please provide reconciliation. No payroll caps are to be applied.
GA-4.1 (Reverse)
The GA-4 New York form must be filled out accurately and submitted within thirty days of the end of each quarter. This form is crucial for reporting and assessing the payroll of municipal self-insured employers. Follow these steps to ensure proper completion of the form.
The GA-4 form is the Quarterly Unified Employer Assessment Municipal Self-Insurers Remittance Form. It is required for all active municipal self-insured employers in New York to report their payroll and calculate assessments related to workers' compensation. This form must be submitted quarterly, along with payment, within thirty days after the end of each quarter.
Every active municipal self-insured employer must complete the GA-4 form. If multiple employers are covered under a single W number, they must also submit the Payroll by FEIN Addendum (GA-4.1) to report payroll for each employer accurately.
The form requires several key pieces of information, including:
The assessment is calculated based on the total payroll reported for the quarter. The formula involves:
The total assessment due is the total loss cost multiplied by the assessment rate.
The form must be submitted within thirty days after the end of each quarter. It is essential to adhere to this timeline to avoid penalties or issues with self-insured status.
Failure to submit the GA-4 form and payment on time can lead to penalties, including interest on any underpaid assessments. Additionally, repeated failures may result in the revocation of self-insured status.
You can submit the completed GA-4 form via email to [email protected] . If you prefer to mail it, send it to:
New York State Workers’ Compensation Board 328 State Street Finance Unit, Room 331 Schenectady, NY 12305-2318
Incorrect WCB Identification Number: Failing to provide the correct WCB Identification Number, also known as the "W Number," can lead to significant issues. This number is crucial for identifying the municipal self-insurer and ensuring that the assessment is properly attributed.
Omitting Required Payroll Information: Some individuals neglect to include the total quarterly payroll associated with both school districts and other municipal employers. This omission can result in an inaccurate assessment and potential penalties.
Not Reporting Excluded Payroll: It is essential to accurately report any payroll that is not subject to assessment. Failing to do so may lead to discrepancies in the total payroll reported, which can complicate the assessment process.
Missing Certification: The certification section must be completed and signed. If this section is left blank or not properly filled out, the submission may be considered incomplete, leading to delays or rejection of the form.
The GA-4 New York form is essential for municipal self-insured employers to report their quarterly assessments. Several other forms and documents are often used in conjunction with the GA-4 to ensure compliance and accurate reporting. Below is a list of these documents, each described briefly.
Understanding these documents is vital for municipal self-insured employers to maintain compliance with New York's Workers' Compensation Board requirements. Proper use of the GA-4 and its related forms will facilitate accurate reporting and timely payments.
The GA-4 New York form shares similarities with the IRS Form 941, which is used by employers to report income taxes, Social Security tax, and Medicare tax withheld from employee's paychecks. Both forms require employers to report payroll information on a quarterly basis. They also necessitate the calculation of total wages paid, which is essential for determining tax liabilities. Just as the GA-4 assesses municipal self-insurers, Form 941 assesses federal tax obligations based on payroll data. Timely submission of both forms is crucial to avoid penalties.
Another document similar to the GA-4 is the New York State Unemployment Insurance (UI) Form NYS-45. This form is used to report wages and calculate unemployment insurance contributions. Like the GA-4, it is submitted quarterly and requires detailed payroll information. Employers must list total remuneration paid during the quarter, which aligns with the payroll reporting requirements of the GA-4. Both forms aim to ensure compliance with state and federal regulations regarding employee compensation and benefits.
The Quarterly Combined Withholding, Wage Reporting, and Unemployment Insurance Return (NYS-45) is also comparable to the GA-4. This document combines several reporting requirements into one form, making it easier for employers to manage their payroll reporting. Similar to the GA-4, it requires reporting of total wages paid and is due on a quarterly basis. Employers must ensure that the payroll figures reported on both forms align, as discrepancies may lead to audits or penalties.
Finally, the Employer's Annual Federal Unemployment (FUTA) Tax Return (Form 940) shares characteristics with the GA-4. While the GA-4 is a quarterly assessment, the Form 940 is an annual report that summarizes unemployment taxes owed. Both forms are focused on payroll data and require accurate reporting to ensure compliance with tax obligations. Employers must maintain detailed records throughout the year to accurately complete both forms, highlighting the importance of consistent payroll management.
When completing the GA-4 New York form, it is essential to follow specific guidelines to ensure accuracy and compliance. Below is a list of seven important dos and don’ts to consider:
Adhering to these guidelines will help facilitate a smoother reporting process and minimize potential issues with the Workers' Compensation Board.
Understanding the GA-4 New York form can be challenging, and misconceptions often arise. Here are eight common misunderstandings regarding this important document:
By clearing up these misconceptions, municipal self-insured employers can navigate the requirements of the GA-4 form more effectively, ensuring compliance and avoiding potential pitfalls.
Here are key takeaways about filling out and using the GA-4 New York form:
Be sure to follow these guidelines to ensure compliance and avoid potential issues.