Free F245-365-000 Provider Account Change Form - Washington


File Size: 388.8 kB
Pages: 1
File Format: PDF
State: Washington
Category: Workers Compensation
Author: Forms & Records Section
Word Count: 261 Words, 1,550 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.lni.wa.gov/Forms/pdf/245365af.pdf

Download F245-365-000 Provider Account Change Form ( 388.8 kB)


Preview F245-365-000 Provider Account Change Form
Provider Account Change Form

Mail to: L&I Provider Accounts PO Box 44261 Olympia, WA 98504-4261 360-902-5140

Use this form to notify L&I of any change to your provider account information. Send to address above. Important: We will need: 1.) Provider Account Name 2.) Federal tax ID # 3.) L&I Provider Number and

4.) Your signature at the bottom.
Provider Account Name: Federal Tax ID: L&I Provider # for individual: L&I Provider # for group:

Change the name on my account
(If you are changing the name of an individual, you must attach documentation: Practice license, marriage license, divorce decree, or court order. You do not need documentation to change your business name.)
Current Provider Name: New Provider Name:

Change the address of my office's physical address
(This is the physical location where you provide services. It cannot be a PO Box.) Current Physical Address
Address City Phone: State ZIP

New Physical Address
Address City Phone: State ZIP

Change my billing address
Current Billing Address
Address City Phone: State ZIP

Check if you want us to send all mail here.
New Billing Address
Address City Phone: State ZIP

(This is where you want L&I to mail your payments.)

Inactivate my L&I account
Provider Number: Reason: Provider Name: Effective Date:

I authorize this change by signing below:
Date: Signature:

Important: Completing this form alone will not update your tax information with L&I.
To do this, you must also send us your updated and signed W-9 form.

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F245-365-000 provider accounts change form 3-09