Department of Labor and Industries Self-Insurance Section PO Box 24442 Seattle WA 98124-0442 CertificationSvcs@Lni.wa.gov 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 296-15-211 (4a). Later 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 costs (auto-filled) 2. Payments made by self-insured 3. Total claim payment (box 1 + box 2) Administrative Assessment 4. Rate 5. AA amount ($25 min) (box 3 x box 4) 6. Previous balance 7. Total AA due (box 5 + box 6) 2nd Injury Assessment 8. Rate 9. 2nd Injury amount (box 3 x box 8) 10. Previous balance 11. Total 2nd Injury due (box 9 + box 10) Insolvency Trust Assessment 12. Rate 13. Ins trust amount (box 3 x box 12) 14. Previous balance 15. Total Insolvency Trust due (box 13 + box 14) 16. Prior Interest balance 17. Prior Penalty balance 18. Prior Interest and Pen due (box 16 + box 17) CLASS HOURS CLASS HOURS CLASS HOURS CLASS HOURS 19. Worker hours 20. Volunteer hours (classes 6901 and 6906) 21. Net worker hours (box 19 - box 20) Supplemental Pension & Asbestos Assessment 22. Rate 25. Previous balance 23. Supplemental Pension and Asbestos amount (box 21 x box 22) 24. Supplemental reimbursement credit (provide Form) 26. Total Supplemental Pension and Asbestos assessment due (box 23 ­ box 24 + box 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) Logger Safety 31. Rate 32. Hours 33. Logger Safety amount (box 31 x box 32) 34. Previous balance 35. Total Logger due (box 33 + box 34) 36. Nmbr of employees/qtr 37. Gross payroll 38. Nmbr new claims/qtr. 39. Total due (boxes 7 + 11 + 15 + 18 + 26+30+35) 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 Print Name and Title Preparer's Phone Signature Date F207-006-000 Quarterly Report for Self-Insured Business 12-2014 Please allow at least seven days for mail service. American LegalNet, Inc. www.FormsWorkFlow.com