Authorization is hereby given to the Department of Labor and Industries to provide our company�s claim history, premium history, developed loss history, statistics, experience modification factor, and related industrial insurance data to the Associated General Contractors of Washington Retro Program. Authorization is effective immediately and granted until withdrawn via our written notification to the Department.

Company Name:

LNI Risk Class Codes:

LNI Account #:

UBI #:

E.M.R.:

Address:
City
State Zip:

Phone:

Fax:

Email:

Company Official:

Title:

Claim & Safety Contact:

Approximate annual premium paid to LNI:

Do you have a full time safety person? Yes No

Are you currently participating in a retrospective rating program? Yes No

If yes, which one?

Printed Name of Company Representative: __________________________________

Signature of Company Representative: _______________________________________ (signature required)

Date: __________________________________

* Please print this form and fax to (888) 737-3876.

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1200 Westlake Ave. N, Suite 301, Seattle WA 98109
Phone - (206) 284-0061; Fax - (206) 285-4546;
E-mail -
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