Workers' Compensation - Employer'S Quarterly Report Form

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0
Washington State Department of
Labor & Industries
PO Box34022
Seattle WA
1022
File online now by going to:
QuarterlyReports.Lni.wa.gov
Use PAC code: 41692333
Policyholder
.
•
Workers'
Compensation
Employer's Quarterly Report
2200 N COMMERCE.PKWYSTE 200
WESTON FU332p32S8
Your business currently has optional workers' compensation coverage
for owners, partners, corporate officers, or LLC members.
YesO
No
ll2l
If marked
yes,
remember to include these hours in the class worked.
L&l Account ID:
236,169-00
Report is for quarter endmg.
122
06-30-2012
WA
Umf1ed Busmess Identifier (UBI):
603 019 817
Due date:
07-31-2012
Questions? Call your Account Manager:
No worker hours this quarter?
You
will
still need to submit a quarterly report.
(See enclosed instruction sheet.)
Enter total worker hours for each class to calculate the premiums you owe this quarter. Instructions are enclosed.
0
ClassCode
6303-00
6
Class Code Description
0
Gross Payroll
0
Worker Hours
X
0
Your Rate
=
0
Premium
- - - - - - - - - - - - - - - - - · - - - - - -
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Make all checks payable to the Department of Labor
&
Industries.
Payment must be postmarked by due date above.
0 . · . · . · .
Subtotl!l
(i)
.. . existing
L&l
previous · •
· balance yqu owed
4tD
Addany!ate
penalties youowe•
G)
·
Add any.late
interestyou owe*
----
,..-
----'""""
__ _
Amountdue
$
*Enclosed instructions explain our late fees.
0
Address or owner change?
Remit 10
$
Please check here and
F212-055-000 [03-201 0]
complete change form.
. .
00615235- onno1
01 - 11 nnnnnn
SAMPLE ONLY

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