Temporary Authorization for Release of Information Legal Name(Required) Doing Business As (if applicable) Physical Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Phone(Required)Email(Required) Company Representative (First & Last Name)(Required) Title(Required) L&I Account ID #(Required) UBI #(Required) FTE Count(Required)Number of FTE (full time equivalent) employees (includes PT employees). Example: 4 PT employees who work 10 hours per week equal 1 FTE.Have you tailored an Accident Prevention Program manual to your location(s)?(Required) Yes No Do you have a safety committee that has regularly scheduled meetings?(Required) Yes No Do you have firm safety policies in place?(Required) Yes No Do you have a new hire safety orientation?(Required) Yes No Can you provide light duty or return to work opportunities, if needed?(Required) Yes No Authorization is hereby given to the Department of Labor & Industries to provide our company’s claim history, premiums, losses, statistics, experience modification factor and related industrial insurance data to Washington Hospitality Association and Employer Resources Northwest. This authorization is to include allowing Washington Hospitality Association and Employer Resources Northwest online access to the Secure Access system and the Claims and Account (CAC) system. The scope of authorization is to include all matters relating to the Department of Labor & Industries and is to begin effective immediately until withdrawn through our written notification to the Department.Your Signature Reset signature Signature locked. Reset to sign again PhoneThis field is for validation purposes and should be left unchanged.
