Option Form for Bonus and/or Lump Sum Payments 
                                                              For Rating Purposes Only 

Choose either the deletion method or the apportion method, then provide the requested information in the appropriate columns. 

        Deletion Method                                                                       Apportion Method
 In Column 3, list annual bonuses or other lump sum payments for service                      In Column 4, list the quarter ending dates that the
 performed over a period of more than three months but reported in a single                   annual bonuses or lump sum payments are to be
 quarter.  For rating purposes these bonuses or lump sum payments will be deleted             apportioned among equally. Service for bonuses and
 entirely from the quarter(s) in which they were paid.                                        lump sum payments must have been performed 
                                                                                              over a period of more than three months to be
 When using the Deletion or Apportion Method, Columns 1, 2, and 3 must be completed.          apportioned equally among the calendar quarters.
 (1) Enter the quarter     (2) List the total wages as   (3) For both methods, list the       (4) Quarter Ending Date(s)       (5) Adjusted total
 ending dates for the      reported on your quarterly    amount of bonuses & lump sum                                            SHADED AREA FOR 
 rating period.            contribution report for the   payments.                                                             DEPARTMENTAL USE ONLY
                           quarter(s) listed in Column 1.

Account  No :    .  _______________________________   Account name: _________________________________________________________  Date: ________________

Contact  erson:p __     ____________________________________ Phone: __ ______________________ Email: _____________________________________________

Page 2                                                                                                                         Form 07-1496-02 (Rev 11 21/ )