Free F207-006-000 Quarterly Report for Self Insured Business - Washington

Department of Labor & Industries Self-Insurance Section PO Box 24442 Seattle WA 98124-0442

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QUARTERLY REPORT FOR SELF-INSURED BUSINESS

This report is required by RCW 51.44.150. The 30 day time limit for filing is set by WAC 296-15-221(4a). Late reporting is subject to a penalty of $500 as provided by RCW 51.48.080. Interest will be charged on past due assessments. This report is subject to verification.
Report must be received by: For qtr. ending: UBI: Account ID: Account Status:
1. State fund claim cost 2. Payments made by self-insured 3. Total claim payment (box 1 + box 2)

Administrative Assessment 4. Rate 5. AA amt. ($25 min) (box 3 X box 4)

6. Previous balance

7. Total AA due (box 5 + box 6)

$0.00
2nd Injury Assessment 8. Rate 9. 2nd injury amt. (box 3 X box 8) Insolvency Trust Assessment 12. Rate 13. Ins trust amt. (box 3 X box 12) 10. Previous balance 11. Total 2nd injury due (box 9 + box 10)

14. Previous balance

15. Total ins trst due (box 13 + box 14)

16. Prior interest balance

17. Prior penalty balance

18. Prior int and pen due (box 16 + box 17)

CLASS

HOURS

CLASS

HOURS

CLASS

HOURS

CLASS

HOURS

Please do not add classes with out contacting the Department
19. Worker hours 20. Volunteer hours (classes 6901 and 6906)

-

Do not use SIC or NAICS Codes
21. Total worker hours (box 19 - box 20)

Supplemental Pension & Asbestos Assessment 23. Supplemental pension & asbestos amount (box 21 X box 22) 22. Rate 25. Previous balance

24. Supplemental reimbursement amount 26. Total supplemental pension & asbestos assessment due (box 23 - 24 + 25)

SI Overpayment Reimbursement Assessment (SIOR)
27. Rate 28. SIOR amount (box 21 x box 27) 29. Previous balance 30. Total SIOR due (box 28 + box 29)

$0.00
31. No. of employees 32. Gross payroll 33. No. new claims/qtr.

$0.00
34. Total due (boxes 7 + 11 + 15 + 18 + 26+30)

I (we) the undersigned hereby certify that the data appearing in the report is an accurate and complete statement of the claim payments and worker hours for the period as stated.
Location of records Type name and title Phone Signature Date

F207-006-000 quarterly report for self-insured business 01-2009

Please allow at least seven days for mail service.