Application for Group Membership & Authorization for Release of Insurance Data
See also
| Document Information | ||
|---|---|---|
 Get help downloading & printing files.  How to complete a fillable form. |
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| Title |
Application for Group Membership & Authorization for Release of Insurance Data (A fillable form - 144 KB PDF)
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| Description | Used by employers who want to join a retrospective rating group; also, to authorize Labor & Industries to release the employers' insurance data to the retrospective rating group they want to join. | |
| Detail | ||
| Form number | F250-016-000 | |
| Availability | Online only. See document above to download. |
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| Keywords | industrial insurance, premiums, reducing premiums, release information, retro, worker's compensation, workers compensation, workers' compensation | |
| Languages | English | |
| Valid dates | 04-2012 | |
| Contact information |
Contact Us About Retrospective Rating
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| Related information | ||
| Documents | Application for Group Retrospective Rating |
|
| Web pages | Qualify for Refunds | |
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