About L&I's Workers' Comp Insurance

Order Form for the Employer Reporting Pilot Project

Order forms and publications	Number needed
Employers Report of Accident (ROA) (F242‑390‑000):
Mailing address	* indicates required field
* Contact name:	Please enter a contact name.
* Business name:	Please enter the business name.
* Business address:	Please enter the business address.
Business address (cont.):
* City, State, and Zip:	Please enter the city. Please enter the zip code.
* Business phone (000‑000‑0000):	Please enter the phone number.
* UBI number:	Please enter the business UBI number.
Click to submit: