Application for Group Membership & Authorization for Release of Insurance Data

Application for Group Membership & Authorization for Release of Insurance Data - (Forms/Publications)
Document Information
  Get help downloading & printing files.   How to complete a fillable form.
Title Application for Group Membership & Authorization for Release of Insurance Data (A fillable form - 144 KB PDF)
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.
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
Related information
Documents Application for Group Retrospective Rating
Web pages Qualify for Refunds

End of main content, page footer follows.

Access Washington official state portal

© Washington State Dept. of Labor & Industries. Use of this site is subject to the laws of the state of Washington.