F242-431-000 Authorization on Behalf of Employer 07-2017 Index: CORR
Employer Services
PO Box 44140
Olympia WA 98504-4140
Fax 360-902-4988
QuarterlyFiling@Lni.wa.gov
www.QuarterlyReports@Lni.wa.gov
Authorization to Access Information Or
File on Behalf of Employer
Claim and Account Access
This Authorization Request is
:
New Update Cancellation
Effective Date
Complete this section about your worker’s compensation account. This form authorizes L&I to share information regarding this
account, quarterly report filing, or claims with the representative listed below.
9 Digit UBI Number: (ex. 603-123-456)____-____-____
8 Digit L&I Account ID: (ex. 123,456-78)____,____-___
Business Name:
Authorized Contact Name:
Address:
City:
State:
Zip:
Phone:
Fax:
Authorized Contact Email Address:
Representative Information
You agree to grant the following representative access to the above account.
Representative Business Name:
Representative Contact Name:
9 Digit Representative UBI Number: (ex. 603-123-456) _____-_____-_____
Address:
City:
State:
Zip:
Phone:
Fax:
Contact Email Address:
Primary Role:
Accountant Payroll PEO* Legal Rep Other (specify):______________
Accesses Granted (select all that apply)
Access Authorized for: Account Quarterly Filing Claims Other (specify):________________
Send Mail To: Employer Representative Other (specify):___________________________
Signature below must be an authorized signer from the employer (e.g. owner, officer, or person with power of attorney). The
signature below
authorizes L&I to release confidential information and grant online access as indicated. If the effective date is blank,
the date signed below will become the effective date
Employer Authorized Contact Printed Name
Employer Authorized Contact Title
Employer Authorized Contact Signature
Please make a copy of this form for your files.
Scan and email this form to QuarterlyFiling@Lni.wa.gov or fax to 360-902-4988.
ADP Tax Services, Inc. a wholly owned subsidiary of ADP, Inc.
