The Quarterly Unified Employer Assessment Municipal Self-Insurers Remittance Form (GA-4) is a crucial document required by the State of New York for municipal self-insured employers. This form must be completed and submitted quarterly to ensure compliance with workers' compensation regulations. By accurately reporting payroll and associated assessments, municipal employers help maintain the integrity of the self-insurance system.
The GA-4 New York form, officially known as the Quarterly Unified Employer Assessment Municipal Self-Insurers Remittance Form, serves a crucial role for municipal employers who have opted for self-insurance in their workers' compensation programs. This form is required to be completed each quarter, ensuring that self-insured employers report their payroll and associated assessments accurately. It encompasses various sections, including vital information about the municipal self-insurer, such as the Workers' Compensation Board (WCB) identification number, the employer's name, and their Federal Employer Identification Number (FEIN). The form also outlines the reporting period and provides a structured way to calculate the basis for assessment, which includes payroll class codes and loss costs. Additionally, it requires a certification from the employer, confirming the accuracy and completeness of the information provided. Employers must submit the GA-4 form along with payment within thirty days after the end of each quarter, making it essential for maintaining compliance with New York's workers' compensation regulations. Understanding the nuances of this form can help municipal employers navigate their obligations and avoid potential penalties associated with inaccurate reporting or late submissions.
Understanding the GA-4 New York form can be challenging, and several misconceptions often arise. Here are five common misunderstandings, along with clarifications to help ensure accurate reporting and compliance.
All active municipal self-insured employers, regardless of size, are required to complete and submit the GA-4 form quarterly. This includes small municipalities as well as larger entities.
Even if there is no payroll, the form must still be submitted. Employers should report their situation accurately, as failure to do so can lead to complications.
The assessment rate can vary annually, as it is set by the Chair of the Workers' Compensation Board. Employers should check for updates each year to ensure they are applying the correct rate.
All municipal employers covered under the same W number must be reported. This includes any additional employers that fall under a county plan or municipal group.
Late submissions can lead to penalties, including interest charges on any underpaid assessments. Timely submission is crucial to maintain compliance and avoid potential issues.
By addressing these misconceptions, employers can better navigate the requirements associated with the GA-4 New York form. Staying informed and compliant is essential for successful self-insurance management.
When filling out the GA-4 New York form, it’s important to follow certain guidelines to ensure accuracy and compliance. Here are some key do's and don'ts:
By following these guidelines, you can help ensure that your submission is complete and accurate, minimizing the risk of issues down the line.
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 WCBFinanceOffice@wcb.ny.gov.
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:
WCBFinanceOffice@wcb.ny.gov
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 WCBFinanceOffice@wcb.ny.gov.
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, officially known as the Quarterly Unified Employer Assessment Municipal Self-Insurers Remittance Form, is a document that municipal self-insured employers in New York must complete and submit quarterly. This form is essential for reporting payroll information and calculating assessments related to workers' compensation. It ensures that municipal employers comply with state regulations regarding self-insurance and assessment payments.
Every active municipal self-insured employer in New York is required to file the GA-4 form. This includes school districts and other municipal employers that are part of a self-insurance program. Employers who have discontinued their self-insurance programs or those who are inactive do not need to submit this form.
The GA-4 form must be completed and submitted within thirty days following the end of each quarter. This means that employers should keep track of their payroll and assessment calculations to ensure timely submission and avoid penalties.
The GA-4 form requires several key pieces of information, including:
Accurate reporting of this information is crucial for compliance and to avoid potential penalties.
The assessment is calculated based on the total payroll reported on the GA-4 form, multiplied by a specific loss cost rate. For municipal employers, this rate is determined annually by the Chair of the Workers' Compensation Board. The total assessment due is then calculated by multiplying the total loss cost by the assessment rate, which is currently set at 13.8%.
If there are multiple employers covered under the same W Number, you must report them using the Payroll by FEIN Addendum (GA-4.1). This addendum allows for the consolidation of payroll information for all employers that are part of the same self-insurance program. It is essential to ensure that all payroll is accurately reported to avoid discrepancies.
Failure to submit the GA-4 form and corresponding payment on time can lead to significant consequences. The Workers' Compensation Board may impose penalties, including interest on underpaid assessments and potential additional penalties for inaccurate reporting. In severe cases, failure to comply could result in the revocation of self-insured status.
The completed GA-4 form should be submitted via email to WCBFinanceOffice@wcb.ny.gov. Additionally, a check made payable to the Chair, NYS Workers' Compensation Board, should be mailed to the following address:
New York State Workers’ Compensation Board 328 State Street Finance Unit, Room 331 Schenectady, NY 12305-2318
After gathering the necessary information, you will fill out the GA-4 New York form. This process involves providing details about your municipal self-insured employer, the reporting period, payroll information, and certifying the accuracy of the report. Follow the steps below to complete the form accurately.
Once you have completed the form, ensure it is submitted along with the required payment within thirty days of the end of the quarter. You can send it via email or mail, as specified in the instructions.
Completing the GA-4 New York form can be straightforward, but many individuals make common mistakes that can lead to delays or complications. One frequent error is not including the correct WCB Identification Number. This number is essential for identifying the municipal self-insured employer and must be accurate to avoid processing issues.
Another common mistake is failing to provide the full legal name of the municipal self-insured employer. Abbreviations or informal names can cause confusion. Ensure that the name matches the one approved for self-insurance. Additionally, omitting the Federal Employer Identification Number (FEIN) can lead to problems. This number is crucial for tax and reporting purposes and must be accurately reported for all employers covered under the W number.
Many people also overlook the importance of specifying the mailing address. The address provided will be used for all correspondence related to the assessment, so it must be complete and correct. Errors in this section can result in missed communications or payment notices.
In the reporting period section, individuals sometimes forget to indicate the correct calendar year and quarter ending. This information is vital for proper assessment and must be filled out accurately. Misreporting these dates can lead to confusion about the assessment period.
When calculating the basis for assessment, many people fail to separate the payroll correctly between school districts and other municipal employers. This distinction is essential for accurate reporting and assessment calculation. Additionally, not adhering to the required loss cost per hundred dollars of payroll can lead to miscalculations that affect the total assessment due.
Another mistake is not including all applicable payroll figures, such as excluded payroll not subject to assessment. This can skew the total payroll figure and lead to incorrect assessment amounts. It is crucial to ensure that all payroll is reported accurately and reconciled with the NYS-45 form.
Individuals often forget to include the total assessment due at the end of the form. This figure is essential for the payment process and must be calculated based on the total loss cost and assessment rate. Without this, the form will be incomplete.
Certification is a critical part of the form. Many individuals neglect to sign or date the certification section. This step is necessary to validate the information provided and confirm that it is accurate. Failure to do so can result in the form being rejected.
Lastly, individuals may not submit the form and payment within the required thirty days of the quarter's end. Timeliness is crucial to avoid penalties or complications with self-insured status. Adhering to deadlines ensures that the self-insured employer remains compliant with state regulations.
Here are some key takeaways regarding the GA-4 New York form for municipal self-insurers:
For any questions, reach out to WCBFinanceOffice@wcb.ny.gov for assistance.
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