F242-431-000 Authorization on Behalf of Employer 10-2017 Employer Services PO Box 44140 Olympia WA 98504-4140 Fax 360-902-4988 QuarterlyFiling@Lni.wa.gov https://secure.lni.wa.gov Authorization to Access Information Or File on Behalf of Employer Claim and Account Access All fields noted as 223required224 must be completed This Authorization Request is (required): Effective Date (required): New Update Remove Access Close Account // Employer Information Complete this section about your worker222s compensation account. This form authorizes L&I to share information regarding this account, quarterly report filing, or claims with the representative listed below. 9 Digit UBI Number: (ex 603-123-456) (required) -- 8 Digit L&I Account ID:(ex. 123,456-78) (required) ,- Business Name (required): Authorized Contact Name (required): Address: City: State Zip Phone(required):Fax: Authorized Contact Email Address(required): Representative Information: You agree to grant the following representative access to the above account. Representative Business Name: Representative Contact Name (required): 9 Digit Representative UBI Number: (ex. 603-123-456) (required): -- Address: City: State Zip Phone (required): Fax: Contact Email Address (required): Primary Role- (required): Accountant Payroll PEO Legal Rep Other (specify): Access Granted Access Authorized for: (Select all that apply) (required): Account Quarterly Filing Claims Other (specify): Send Mail to:(choose one) (required) Employer Representative Other (specify): Signature Signature below must be an authorized signer from the employer (e.g. owner, office, or person with power of attorney). The signature below authorizes L&I to release confidential information and grant online access as indicated. If the effective date is blank, the date signed below will become the effective date. Employer Authorized Contact Printed Name (required): Employer Authorized Contact Title (required): Employer Authorized Contact Signature (required): Date: Please make a copy of this form for your files Scan and email this form to QuarterlyFiling@Lni.wa.gov or fax to 360-902-4988 American LegalNet, Inc. www.FormsWorkFlow.com F242-431-000 Authorization on Behalf of Employer 10-2017 Instructions to Complete the Authorization to Access Information or File on Behalf of Employer Form The Authorization to Access Information or File on Behalf of Employer form grants L&I permission to share confidential information or grant online access to a business account, quarterly report filings, and claims. Authorization Request Check the applicable box indicating whether this authorization is new, updates a current authorization on file, removes access or close account (checking new cancel all previous authorizations). Enter the date this authorization becomes effective (normally the first date of the quarter ex. 7/1/2017). Employer Information Provide complete information about the business and person granting authorization to an L&I workers compensation account. Authorization must include the following information to be approved: 9 Digit UBI Number This is the 9-digit Unified Business Identifier (UBI) number issued by Department of Revenue (DOR) when starting a business. Most UBI numbers begin with the number six (6) and follow the format: 603-123-456 (NOTE: This is not the tax ID/EIN/FEIN number issued by the IRS). 8 Digit L&I Account ID This is the 8-digit Account ID number issued by L&I when a workers compensation account is opened. It follows the format 123,456-78. This number is located on the employer222s Rate Notice, New Account Packet and other L&I correspondence. TIP: Look up a UBI or Account ID at https://secure.lni.wa.gov/verify and search the business name. Legal or DBA name of the business Person authorizing access to the employer information. To complete this section, you must be an authorized signer (generally, a business owner, partner, corporate officer, or LLC member listed on the L&I policy (or other Washington State records). If L&I cannot verify you as an authorized signer, it is your responsibility to provide supporting documentation indicating you are authorized to give this permission. Employer authorized contact information, including address, phone/fax numbers, and email address. Representative Information Provide complete information regarding the person or company authorized to access the employer account. Authorization must include the following information to be approved: Name of the business and person receiving access to the employer account. 9 Digit UBI Number of the business receiving access. Representative contact222s full mailing address, phone/fax numbers, and email address. Check the box indicating the representative222s primary role between the employer and L&I. PEO*: L&I defines a PEO as a co-employment firm who supplies workers (leases employees) and shares experience with the employer. For purposes of this application, L&I will set up a sub-account (not grant access) for the PEO only if they specify 223PEO224 in the Access Granted 221Other222 section. Access(es) Granted Indicate which access(es) should be allowed for the Employer222s worker compensation account. For each access authorized, indicate where L&I should send mail (to the employer or representative). Note: This does not change the official business mailing address for sending information to employer. Signature To complete this section, you must be an authorized signer (see Employer Section for definition of whom L&I considers an authorized signer). If no effective date is indicated above, the date signed will be used. Send to L&I Keep a copy of this completed form for your files. Email a signed, scanned copy of this form to QuarterlyFiling@Lni.wa.gov or fax to 360-902-4988. American LegalNet, Inc. www.FormsWorkFlow.com