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Employer'S Quarterly Report For Industrial Insurance (Worker'S Compensation) Form - Sample - 2005

DEPARTMENT OF LABOR & INDUSTRIES

EMPLOYER’S QUARTERLY REPORT

INSURANCE SERVICES.

You may process your report and payment online at:

FOR INDUSTRIAL INSURANCE

www. LNI.wa.gov/expressfiling

(WORKER’S COMPENSATION)

Check here if changes are made on reverse of white copy.

Please note - you MUST submit a Quarterly

Report even if you had no workers.

Team #

UBI Number :

Account ID

This Report is for

Quarter Ending

TO AVOID PENALTY - This Report MUST be

POSTMARKED and mailed with payment

NO LATER THAN:

GROSS

COMPOSITE

WORKER

CLASS

NATURE OF WORK

PREMIUM

PAYROLL

RATE PER

SUB

HOURS/UNITS

(NEAREST DOLLAR)

HOUR.UNIT

SAMPLE ONLY

NOT FOR USE

Report prepared by (print name)

Preparer’s telephone number

TOTAL OF

PREMIUMS (COLUMN 7)

Official position

Check type of organization

Corp

LLC

PENALTY FOR LATE REPORTING

(SEE BACK OF CANARY COPY)

Individual

Partnership

Other

I declare under the penalty of perjury of the laws of the state of Washington (RCW 9A.72.020) that the

INTEREST - 1% FOR EACH

information contained in this report and in any attachment is true and correct.

MONTH LATE REPORTING

Employer’s Phone #

Date

Signature

AMOUNT DUE

FOR THIS QUARTER

PREVIOUS BALANCE

(DUE OR CREDIT)

GRAND TOTAL TO BE SUB-

This Address

MITTED WITH THIS REPORT

Must Show

Through Return

MAKE CHECK PAYABLE

Envelope Window

TO LABOR & INDUSTRIES

For Dept. use only

Caution - Fold on red dotted line so that only address in shaded area above shows through window

of enclosed envelope.

Remit #

. . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . .

Return white copy with payment.

Keep canary copy for your records.

Employer'S Quarterly Report For Industrial Insurance (Worker'S Compensation) Form - Sample - 2005

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