Employer'S Quarterly Report For Industrial Insurance (Worker'S Compensation) Form - Sample - 2005 Page 3
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1
2
3TO REPORT CHANGES, COMPLETE THIS SECTION.
PLEASE MAKE A COPY FOR YOUR RECORDS.
1. Change of address - Type of change - (please check)
J
J
New business location
Mailing address change only
J
J
Replaces previous location
Both location and mailing address change
J
J
Additional location
Name/address change or correction
(attach additional forms if necessary)
______________________
/
/
Effective date of change:
Location address
Mailing address
Business name
Business name
New location address
Mailing address
City
State ZIP+4
City
State ZIP+4
Phone No.
Fax No.
(
)
2. Ownership change
Entity change
Sold/leased
3. Business closure
J
J
J
J
J
Business was:
Discontinued
Other
If sold/leased, the name of new owner/lessee.
Phone No.
Effective date of change
Date employment ceased
/
/
/
/
New location address
Location (address) of books/payroll records
City
State ZIP+4
City
State ZIP+4
If not sold, explain change: (some changes require completion of Master
Name and mailing address of person authorized to receive refund.
Application)
City
State ZIP+4
I certify that I am authorized to receive any refund of money (with the exception of Retrospective Rating Refunds) held by the State of Washington
for the business.
Phone No.
Title
Required Authorizing Signature
(
)
If the nature of business has changed through activities started or discontinued, change in occupation or other changes, please explain:
SAMPLE ONLY
NOT FOR USE
F212-055-000 quarterly report backer 1 9-05
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