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The GA-4 New York form, officially known as the Quarterly Unified Employer Assessment Municipal Self-Insurers Remittance Form, plays a crucial role for municipal self-insured employers in New York. This form is required to be completed quarterly and submitted within thirty days after the end of each quarter. It collects essential information about the self-insured employer, including the WCB identification number, the legal name of the employer, and the Federal Employer Identification Number (FEIN). The form also outlines the reporting period and the basis for assessment, which includes payroll data and applicable loss costs. Employers must categorize their payroll into specific groups, such as school districts and other municipal employees, to determine the total assessment due. Additionally, if multiple employers are covered under the same W number, an addendum (GA-4.1) must be included to ensure accurate reporting. The form not only facilitates the assessment process but also ensures compliance with state regulations regarding workers' compensation self-insurance.

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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

 

Various

All Other Municipal Employees

 

$1.80

 

 

(6) Subtotal Payroll

$0

 

 

(7) Excluded Payroll Not Subject to Assessment (if applicable)

 

 

 

 

(8) Total Payroll = (6) + (7)

$0

 

 

 

 

 

(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

Municipal Self-Insurers Remittance Form

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)

QUARTERLY UNIFIED EMPLOYER ASSESSMENT

Municipal Self-Insurers Remittance Form

Payroll by FEIN Addendum

State of New York - Workers' Compensation Board

A. Municipal Self-Insurer Information

 

 

2. Name of

1. WCB Identification

 

Municipal Self-

Number:

 

Insured Employer:

 

 

 

 

"W Number"

B.Reporting Period

1.Calendar Year:

2.Quarter Ending:

C.Municipal Employers Covered Under the W Number Shown Above

 

 

 

(4) Excluded

 

 

(3) Quarterly

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)

 

$0

 

 

 

 

GA-4.1(Instructions on Reverse)

Instructions for Completing Quarterly Unified Employer Assessment

Municipal Self-Insurers Remittance Form

Payroll by FEIN Addendum

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.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) .

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 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)

➤ PDF File

Form Specifications

Fact Name Details
Form Purpose The GA-4 form is used for the Quarterly Unified Employer Assessment Municipal Self-Insurers Remittance in New York State.
Submission Frequency Every active municipal self-insured employer must complete and submit the form quarterly, within thirty days after the end of each quarter.
Governing Law This form is governed by the New York Workers' Compensation Law, specifically WCL Section 151.
Required Information Employers must provide their WCB Identification Number, name, FEIN, and mailing address on the form.
Assessment Rate The assessment rate is set annually by the Chair of the Workers' Compensation Board and is currently 13.8%.
Payment Instructions Payments should be made payable to the Chair, NYS Workers' Compensation Board, and can be submitted via mail or email along with the completed form.

Ga 4 New York: Usage Guidelines

Completing the GA-4 form is an essential task for municipal self-insurers in New York. This form needs to be filled out accurately and submitted on time to ensure compliance with state regulations. Below are the steps to guide you through the process of filling out the GA-4 form.

  1. Obtain the GA-4 form, ensuring you have the most recent version.
  2. Fill in the WCB Identification Number>, which is your assigned "W Number."
  3. Enter the Name of Municipal Self-Insured Employer in the designated field.
  4. Provide your FEIN (Federal Employer Identification Number).
  5. Complete the Mailing Address section with your number and street, city, state, and zip code.
  6. Indicate the Calendar Year and the Quarter Ending date.
  7. For the Basis for Assessment, enter the Payroll Class Code and Description of the payroll.
  8. Report the Total Quarterly Payroll for each class.
  9. Calculate the Loss Cost Per Hundred Dollars for each category and multiply by the total payroll.
  10. Sum the results to find the Total Loss Cost.
  11. Apply the Assessment Rate of 13.8% to the total loss cost to determine the Total Assessment Due.
  12. Sign the form in the Certification section, including your title, printed name, date, and phone number.

After completing the form, ensure that you submit it along with any required payment within thirty days of the quarter's end. Remember to include your "W Number" on any checks made payable to the Chair, NYS Workers' Compensation Board. It is crucial to maintain accurate records and adhere to deadlines to avoid penalties or complications with your self-insured status.

Your Questions, Answered

What is the GA-4 New York form?

The GA-4 New York form, also 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 each quarter. This form is essential for reporting payroll and calculating assessments related to workers' compensation. It ensures compliance with state regulations and helps maintain accurate records for self-insured employers.

Who is required to file the GA-4 form?

Every active municipal self-insured employer in New York must file the GA-4 form. This includes entities like school districts and other municipal employers that have been approved to self-insure for workers' compensation. If an employer has discontinued its self-insurance program, they are not required to submit this form.

What information do I need to complete the GA-4 form?

To complete the GA-4 form, you will need several key pieces of information. This includes your WCB Identification Number (or "W Number"), the full legal name of your municipal self-insured employer, your Federal Employer Identification Number (FEIN), and your mailing address. You will also need to report your total quarterly payroll and the basis for assessment, including loss costs and assessment rates.

When is the GA-4 form due?

The GA-4 form must be submitted within thirty days after the end of each quarter. Timely submission is crucial to avoid penalties and ensure compliance with state regulations. Mark your calendar to help you remember these deadlines!

What happens if I miss the GA-4 filing deadline?

If you fail to submit the GA-4 form by the deadline, you may face penalties. The Workers' Compensation Board may impose interest on any underpaid assessments, and repeated failures could lead to revocation of your self-insured status. It's important to stay on top of these deadlines to avoid complications.

How do I calculate the total assessment due on the GA-4 form?

The total assessment due is calculated by multiplying the total loss cost by the assessment rate. The assessment rate is established annually by the Chair of the Workers' Compensation Board. Make sure to refer to the form for the most current rates to ensure accurate calculations.

Can I report multiple employers on the GA-4 form?

Yes, if multiple employers are covered under the same W number, you must report them using the Quarterly Unified Employer Assessment Municipal Self-Insurers Remittance Form - Payroll by FEIN Addendum (GA-4.1). This addendum allows you to consolidate payroll information for all employers under your W number.

How do I submit the GA-4 form?

You can submit the completed GA-4 form via email to [email protected]. Additionally, you must mail a check made payable to the Chair, NYS Workers' Compensation Board, to the specified address. Ensure that your W number and applicable quarter are included on the check for proper processing.

What if I have questions about the GA-4 form?

If you have questions or need assistance with the GA-4 form, you can reach out directly to the Workers' Compensation Board at [email protected]. They are available to help clarify any uncertainties you may have regarding the form or the filing process.

What are the consequences of inaccurate reporting on the GA-4 form?

Inaccurate reporting can lead to significant consequences, including penalties and interest on underpaid assessments. If it is determined that you knowingly reported incorrect information, you could face additional penalties. Maintaining accurate records and reporting is essential to avoid these issues.

Common mistakes

  1. Incorrect WCB Identification Number: Many individuals mistakenly enter an incorrect or outdated WCB Identification Number, also known as the "W Number." This number is crucial for identifying the self-insured employer and ensuring accurate processing of the form.

  2. Missing Full Legal Name: It is common for people to abbreviate or provide a different name than the full legal name of the municipal self-insured employer. This can lead to confusion and delays in processing.

  3. Inaccurate FEIN Reporting: Failing to report the correct Federal Employer Identification Number (FEIN) is another frequent error. The FEIN must correspond to the municipal self-insurer, and any discrepancies can result in complications.

  4. Improper Mailing Address: Some individuals neglect to provide the complete mailing address, including the street number, city, state, and zip code. This omission can hinder communication and affect the submission process.

  5. Failure to Report Excluded Payroll: When applicable, individuals often forget to report excluded payroll not subject to assessment. This can lead to inaccuracies in the total payroll calculations.

  6. Misunderstanding the Assessment Basis: There is a tendency to misunderstand how to calculate the total loss cost based on the payroll and the loss cost per hundred dollars. This misunderstanding can lead to incorrect total assessments.

  7. Late Submission of the Form: Many fail to submit the form and payment within the required thirty days after the quarter ends. Late submissions can result in penalties and complications with self-insured status.

Documents used along the form

The GA-4 New York form, known as the Quarterly Unified Employer Assessment Municipal Self-Insurers Remittance Form, is a crucial document for municipal self-insured employers in New York. Along with this form, several other documents are often utilized to ensure compliance with reporting requirements and to provide comprehensive information about payroll and assessments. Below are five important forms and documents that are typically used in conjunction with the GA-4.

  • GA-4.1: Payroll by FEIN Addendum - This addendum is required when multiple employers are approved to self-insure under the same W number. It details the payroll for each employer, ensuring that all relevant information is accurately reported and assessed.
  • NYS-45: Quarterly Combined Withholding, Wage Reporting and Unemployment Insurance Return - This form is essential for reporting employee wages and taxes withheld. It provides a summary of total remuneration paid during the quarter, which should align with the payroll reported on the GA-4.
  • WCB Audit Request Form - In instances where the Workers' Compensation Board conducts audits, this form may be required. It allows the board to request specific information and documentation related to self-insured employers’ assessments and payments.
  • Assessment Rate Notification - This document provides the current assessment rate set by the Chair of the Workers' Compensation Board. It is important for employers to reference this rate when calculating their total assessment due on the GA-4 form.
  • Self-Insurer Application Form - For entities seeking to become self-insured, this form is necessary. It collects detailed information about the employer and must be approved by the Workers' Compensation Board before self-insurance can commence.

Utilizing these documents alongside the GA-4 form helps ensure that municipal self-insured employers remain compliant with New York's workers' compensation regulations. Understanding the purpose and function of each form can alleviate confusion and streamline the reporting process, ultimately supporting the financial health of municipal entities.

Similar forms

The GA-4 New York form is similar to several other documents that serve similar purposes in the realm of employer assessments and reporting. Here are six documents that share similarities with the GA-4 form:

  • NYS-45: This is the Quarterly Combined Withholding, Wage Reporting and Unemployment Insurance Return. Like the GA-4, it requires employers to report payroll information on a quarterly basis. Both forms ensure that accurate payroll data is submitted for assessment purposes.
  • WC-1: The Workers' Compensation Self-Insurance Application is used by employers seeking to self-insure their workers' compensation liabilities. It shares the goal of documenting employer compliance with state regulations, similar to the GA-4.
  • GA-4.1: This is the Payroll by FEIN Addendum. It is directly related to the GA-4 form and is used to report additional municipal employers under the same W number. Both forms must be submitted together to provide a complete assessment of payroll.
  • DB-300: The Disability Benefits Law Employer Registration form is required for employers in New York to register for disability benefits. Similar to the GA-4, it involves reporting employer information and ensures compliance with state regulations.
  • WCB-1: The Workers' Compensation Board Employer Registration form is used for employers to register with the Workers' Compensation Board. It serves a similar purpose in establishing compliance and ensuring proper reporting of employer information.
  • Form 1099: This form is used to report various types of income other than wages, salaries, and tips. Like the GA-4, it is a reporting tool that helps ensure accurate financial reporting for tax purposes, although it serves a different context.

Dos and Don'ts

When completing the GA-4 New York form, there are several important guidelines to follow. Adhering to these can help ensure accuracy and compliance.

  • Do complete the form each quarter within thirty days after the end of the quarter.
  • Do use the full legal name of the municipal self-insured employer as registered.
  • Do report the Federal Employer Identification Number (FEIN) accurately.
  • Do include the WCB Identification Number (W Number) assigned to the municipal self-insurer.
  • Do ensure that total payroll reported aligns with the Quarterly Combined Withholding, Wage Reporting and Unemployment Insurance Return (NYS-45).
  • Don't submit the form without the required payment attached.
  • Don't neglect to report additional employers covered under the same W Number.
  • Don't use outdated rates for loss cost calculations; verify the current rates set by the Chair.
  • Don't ignore the certification section; an inaccurate report may lead to penalties.

Misconceptions

Understanding the GA-4 New York form is crucial for municipal self-insured employers. However, several misconceptions can lead to confusion. Here are eight common misunderstandings:

  • Only large employers need to file the GA-4 form. Many believe that only large municipal employers are required to submit this form. In reality, all active municipal self-insured employers must file quarterly, regardless of size.
  • Filing is optional if there are no claims. Some employers think that if they haven't had any claims, they can skip filing. This is incorrect; the GA-4 must be submitted each quarter, regardless of claims activity.
  • The GA-4 form is the same as the NYS-45 form. While both forms deal with payroll, they serve different purposes. The NYS-45 is for unemployment insurance, while the GA-4 focuses on workers' compensation assessments.
  • Assessment rates are fixed and do not change. Many assume that assessment rates remain constant. In fact, these rates can be adjusted annually by the Chair of the Workers' Compensation Board.
  • All payroll is subject to assessment. Some employers mistakenly believe that all payroll is included in the assessment calculation. However, certain types of payroll may be excluded, and it’s important to identify these accurately.
  • Late submissions incur only a small penalty. Employers often underestimate the consequences of late submissions. Failing to submit on time can lead to significant penalties, including interest charges and possible revocation of self-insured status.
  • Only the primary employer needs to report. If a municipal employer is part of a group or county plan, all employers under the W number must be reported on the GA-4 form. This is essential for accurate assessment calculations.
  • Questions about the form can be directed to anyone. Some employers are unsure where to seek help. It's crucial to direct any questions to the designated email, [email protected], to ensure accurate information and guidance.

Addressing these misconceptions can help ensure compliance and avoid unnecessary penalties. Understanding the requirements of the GA-4 form is essential for every municipal self-insured employer.

Key takeaways

Here are key takeaways for completing and using the GA-4 New York form:

  • The GA-4 form must be filled out quarterly by all active municipal self-insured employers.
  • Submit the completed form and payment within thirty days after the quarter ends.
  • Include all additional municipal employers under the same W number using the GA-4.1 addendum.
  • Make checks payable to the Chair, NYS Workers' Compensation Board, and include the W number and quarter on the check.
  • Ensure that the total payroll reported aligns with the NYS-45 form; discrepancies require reconciliation.
  • The assessment rate is set annually and is currently at 13.8% of the total loss cost.
  • Certification of the information is mandatory; inaccurate reporting may lead to penalties or revocation of self-insured status.
  • For questions, contact the Workers' Compensation Board at [email protected].