Temporary Authorization for Release of Information

Physical Address(Required)
Have you tailored an Accident Prevention Program manual to your location(s)?(Required)
Do you have a safety committee that has regularly scheduled meetings?(Required)
Do you have firm safety policies in place?(Required)
Do you have a new hire safety orientation?(Required)
Can you provide light duty or return to work opportunities, if needed?(Required)
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is to include all matters relating to the Department of Labor & Industries and is to begin effective immediately until withdrawn through our written notification to the Department.
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