Form Bls-700-028e - Business License Application Page 4
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45. Employment / Elective Coverage
Employment accounts
cannot be established unless you plan to employ persons within the next 90 days. If accounts are
established, employment tax returns will be required quarterly even if you have not hired.
a.
Date of first employment or planned employment at this location: _______________ first date wages paid: _______________
/
/
/
/
MM
DD
YY
MM
DD
YY
b.
Number of persons you employ or plan to employ at this location
: _______________
(do not include owners)
c.
estimate the number of persons under age 18 (minors) you will employ in the next 12 months and duties they will perform:
Number
Duties to be performed by minors (Check )
ages 16-17:
__________
____________________________________________________________________________
ages 14-15:
__________
____________________________________________________________________________
Under age 14: __________
____________________________________________________________________________
d.
Check the ONE box which best describes the major operation of your business.
(01)
(05)
(09)
(13) Retail/Whlsl:
Drywall operations
Maritime/Vessels/Longshore
VehicleSvcs/Transportation
Stores & Warehsing
(02)
(06)
(10)
(14)
Logging/forestry
electronics/Utilities/Vending Mch
Mfg - Chem/Textiles/paper
food Svcs/Chore/asst Lvg/Janitor
(03)
Construction/engrg/property Mgmt
(07)
Wood prod/Stone/glass & Mining
(11)
Mfg - food/Ice/Beverages
(15)
Media/entertainment/Lodging
(04)
(08)
(12)
(16)
Temp Help Co/employee Leasing
Mfg - Metal/Mach Shops/Millwright
agriculture/farming
I.T./prof Svcs/Med/Salon/Schools
e.
Describe in detail the activities of your workers. Then estimate the total workers’
3-Month estimate
.
hours for a 3-month period
(one full-time worker = 480 total hours for 3 months.)
Number of
Workers’ Hours
Workers
(Include Minors)
Example:
Office Staff - reception, accounting, data entry
2
960
f.
If you have more than one Washington location, how do you wish to receive the following quarterly reports?
Unemployment Insurance:
all locations combined
each location separately (multiple reports)
Workers’ Compensation:
all locations combined
each location separately (multiple reports)
Additional Coverage
is available as noted below.
(See License Fee Sheet for more information.)
g.
If you are a profit corporation, do you want unemployment insurance coverage for corporate officers?
Yes – go to esd.wa.gov to obtain a Voluntary election form. This form is required for coverage.
No – The corporation must inform officers in writing that they are not covered for Unemployment Insurance.
h.
Do you want workers’ compensation coverage for owners (sole proprietor, partners, corporate officers, LLC members/
managers)?
(In an LLC with managers, you may elect to cover those persons who are both members (owners) and managers. In an LLC
with members only, you may elect to cover those members.)
Yes – prior to coverage, form f213-042-000 is required. This form will be sent to you by the Dept. of Labor & Industries.
No
i.
Do you want elective workers’ compensation coverage for excluded employment?
(See License Fee Sheet for descriptions.)
Yes – prior to coverage, form f213-112-000 is required. This form will be sent to you by the Dept. of Labor & Industries.
No
6. Signature
Signature of sole proprietor or spouse, partner, corporate officer, or limited liability member/manager.
I, the undersigned, declare under the penalties of perjury and/or the revocation of any license granted, that I am the applicant or authorized
representative of the firm making this application and that the answers contained, including any accompanying information, have been examined
by me and that the matters and things set forth are true, correct and complete.
X
/
/
________________________________________________________________________________________
_______________________
Signature Required
Date
(
)
/
/
_____________________________________________________________________
_______________________________
____________________________
application prepared By (Please Print)
Title
Telephone No.
Date
Some agencies can provide language assistance. Would you like assistance?
Yes
No
Specify language
BLS-700-028e (11/21/13) page 4 of 4
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