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Get WA F212-055-000 2010-2024

Payment must be postmarked by due date above. Address or owner change Please check here and complete change form. F212-055-000 03-201 0 00615235- onno1 01 - 11 nnnnnn Subtotl l. Labor Industries PO Box34022 Seattle WA Workers Compensation 236 169-00 Employer s Quarterly Report Washington State Department of Report is for quarter endmg. L l Account ID File online now by going to 06-30-2012 WA Umf1ed Busmess Identifier UBI QuarterlyReports. Lni. wa*gov Use PAC code 41692333 603 019 817 Due date Policyholder 07-31-2012. 2200 N COMMERCE*PKWYSTE 200 WESTON FU332p32S8 SAMPLE ONLY Questions Call your Account Manager No worker hours this quarter You will still need to submit a quarterly report. See enclosed instruction sheet. Your business currently has optional workers compensation coverage for owners partners corporate officers or LLC members. YesO No ll2l Enter total marked yes remember to include these hours in the class worked* this quarter. Instructions are enclosed* If worker hours for each class to calculate the premiums you owe ClassCode Class Code Description ---------------- - -- - - - - 6303-00 - Gross Payroll Worker Hours X. -. -- - 7c- Your Rate -------- Premium. -. --- - - - - -. - Sales Personnel NOC-Outside ----. - ----. Preparer First Last I Daytime Phone l declare underthe -- Signature inthls -re. port aod in X any attachment is trVe. i previous balance yqu owed 4tD Addany ate penalties youowe G and corre ct. -- Make all checks payable to the Department of Labor Industries. existing L l oi le iury of of the laws oftl e RC. 9A. 7. 020 that the in E-mail 0. interestyou owe Amountdue Enclosed instructions explain our late fees. Labor Industries PO Box34022 Seattle WA Workers Compensation 236 169-00 Employer s Quarterly Report Washington State Department of Report is for quarter endmg. L l Account ID File online now by going to 06-30-2012 WA Umf1ed Busmess Identifier UBI QuarterlyReports. L l Account ID File online now by going to 06-30-2012 WA Umf1ed Busmess Identifier UBI QuarterlyReports. Lni. wa*gov Use PAC code 41692333 603 019 817 Due date Policyholder 07-31-2012. 2200 N COMMERCE*PKWYSTE 200 WESTON FU332p32S8 SAMPLE ONLY Questions Call your Account Manager No worker hours this quarter You will still need to submit a quarterly report. Lni. wa*gov Use PAC code 41692333 603 019 817 Due date Policyholder 07-31-2012. 2200 N COMMERCE*PKWYSTE 200 WESTON FU332p32S8 SAMPLE ONLY Questions Call your Account Manager No worker hours this quarter You will still need to submit a quarterly report. See enclosed instruction sheet. Your business currently has optional workers compensation coverage for owners partners corporate officers or LLC members. See enclosed instruction sheet. Your business currently has optional workers compensation coverage for owners partners corporate officers or LLC members. YesO No ll2l Enter total marked yes remember to include these hours in the class worked* this quarter. YesO No ll2l Enter total marked yes remember to include these hours in the class worked* this quarter. Instructions are enclosed* If worker hours for each class to calculate the premiums you owe ClassCode Class Code Description ---------------- - -- - - - - 6303-00 - Gross Payroll Worker Hours X. .

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