Free F249-017-000 application for inclusion on list of eligible attorneys - Washington

DEPARTMENT OF LABOR AND INDUSTRIES

Worker's Compensation Special Assistant Attorney General Program Third Party Section P.O. Box 44288 Olympia, WA 98504-4288
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APPLICATION FOR INCLUSION ON LIST OF ELIGIBLE ATTORNEYS

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FIRM _______________________________________________________ ADDRESS _______________________________________________________ CITY STATE ZIP

ACTIVE MEMBER OF STATE BAR ASSOCIATION NO YES WSBA NUMBER_________________________ I have an attorney trust account that complies with the Washington Rules of Professional Conduct NO YES ACCOUNT NO._________________________________ NAME OF BANK OR INSTITUTION:__________________________________

I HAVE IN FORCE PROFESSIONAL LIABILITY INSURANCE NO YES POLICY NUMBER & INSURANCE CARRIER

STATES LICENSED IN AREAS OF EMPHASIS IN TORT LAW (OPTIONAL) COUNTIES WHERE WILLING TO PRACTICE:

ACCEPT CASES WITH L&I CLAIM COSTS:

under $1,000

$1,000 - $5,000

over $5,000

I agree to inform the Department of Labor & Industries of any changes to my qualification as stated above. I recognize that this application, and inclusion on the list, does not give me any right to or expectation of employment as a Special Assistant Attorney General. I declare under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct. Please duplicate for your records and mail original to: DEPARTMENT OF LABOR AND INDUSTRIES Workers Compensation Special AAG Program Third Party Section PO Box 44288 Olympia WA 98504-4288 (360) 902-5103
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DATE: ______________________________________

UBI#:________________________________________________ SS or Fed ID#:_________________________________________ L&I Account #:________________________________________

F249-017-000 Application for Inclusion on List of Eligible Attorneys 05-06