Form F225-004-000 - Wa Workers' Compensation Form

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Rate Notice: WA Workers’ Compensation
THIS IS
Effective Date:
Experience Factor
4
:
NOT A
State of Washington
Department of Labor and Industries
BILL
PO Box 44140
Experience Period:
Olympia WA 98504-4140
WA Unified Business Identifier (UBI):
Policyholder
L&I Account ID:
PAC Number:
Account Manager:
SAMPLE
Pay your premiums online:
Have a payroll service?
Need help understanding this notice? Call your account manager at the phone number shown above.
Send them a copy of this notice.
Stay at
Supp.
Hourly*
Medical
= Your Total
Accident
Class Code Description
Employer
Work
Pension
Aid Fund
Hourly* Rate
1
Fund (AF)
3
5
Contribution
(MA)
2
Program
Fund (SP)
[(1+2+3)x4]+5
Withhold this
On the
This is the
Your experience
Quarterly
employer’s
amount from
Report, the
contribution
employee
factor history:
employer will
pay for each
to workers’
hour* they
multiply this
comp coverage.
number by the
work. It is their
hours* worked
contribution to
What’s an experience factor?
to calculate
workers’ comp
See back for an explanation.
coverage.
premiums.
F225-004-000 [12-2013]
* Hours or units.

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