AGREEMENT between BROWARD COUNTY and Cummings ...

Form-4
Monthly On-Site(s) Payroll Report Form 4
Numbers reference attached instructions
Exhibit 2
Page 136 of 379
BROWARD COUNTY, FL
Page 1 of 2
Complete a Separate Form for Each Contract with BROWARD COUNTY.
Your report is due to the Aon Insurance Administrator, identified below, no later than the 10 th day of the succeeding month.
Complete this report even though no work was performed; enter zero (0) for the Reportable Payroll.
Delay in providing this report may result in payments being withheld.
A. REPORT IDENTIFICATION
B. ACTIVITY REPORT
Period Beginning:
1
Period Ending:
2
Year:
3
4
Contractor:
5
Under Contract with:
Contract #:
6
BROWARD COUNTY
1
a b
c d e f
State Workers’ Comp.
Work Description Man-Hours Gross Payroll Reportable Payroll *
Class Code
2 3 4
TOTALS:
* Do not include premium (excess) overtime wages, use straight time wage rates only. You must also comply with all rules set forth by the Workers Compensation Bureau in the
state in which the work is performed.
C. ADDITIONAL DATA REQUIREMENTS :
1.
2.
3.
D. Signature Block : I verify the information presented above and attachments are correct:
Name:
Title:
(please print)
Date:
Signature:
CHECK IF THIS IS YOUR LAST PAYROLL REPORT. COMPLETE AN AON FORM-5 “NOTICE OF WORK COMPLETION” AND INCLUDE
WITH THIS PAYROLL REPORT.
Note: Information can be submitted on-line at www.aonwrap.aon.com. Please contact your Administration Staff to
obtain a user ID and Password.
Fax or Mail to: Diana Schrader Phone: 407.804.2418
Aon Risk Services, Inc. of Florida Fax: 407.804.1077
400 International Parkway, Suite 100 Email: Diana. Schrader@.aon.com
Heathrow, FL 32746