Form F213-004-000 "Cancellation of Elective Coverage - Sole Proprietors/Partner, Member of Limited Liability Company (LLC), Member of Limited Liability Partnership (LLP ) or for-Profit Corporate Officers" - Washington

What Is Form F213-004-000?

This is a legal form that was released by the Washington State Department of Labor and Industries - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2018;
  • The latest edition provided by the Washington State Department of Labor and Industries;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form F213-004-000 by clicking the link below or browse more documents and templates provided by the Washington State Department of Labor and Industries.

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Download Form F213-004-000 "Cancellation of Elective Coverage - Sole Proprietors/Partner, Member of Limited Liability Company (LLC), Member of Limited Liability Partnership (LLP ) or for-Profit Corporate Officers" - Washington

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Cancellation of Elective Coverage
Sole Proprietor/Partner, Member of Limited Liability
Company (LLC), Member of Limit Liability Partnership
(LLP), or For-Profit Corporation Officers
I, the undersigned, being either a sole proprietor, partner, member of an LLC or LLP or corporate officer of the
corporation listed below, do hereby cancel coverage.
Cancellation for corporate officers or LLCs with managers is effective 30 days after receipt of this signed
cancellation notice, or on request, provided that the requested date is at least 30 days after the written notice is
received by the department.
Cancellation for sole proprietors, partners, LLCs where management is vested in its members, or LLPs, is
effective immediately upon receipt of this signed cancellation notice. Liability for payment of premiums is
through the date of cancellation as indicated by written notification from the department.
I understand that if, as a sole proprietor, partner, member of an LLC or LLP or corporate officer(s) at a later
date, I again want the protection of the Workers’ Compensation Act, I must submit a written application to the
Department of Labor & Industries and coverage will not become effective until the day after the written
application is received by the department or a future date I request.
Owner Coverage as provided by RCW 51.32.030 (each owner, partner, LLC, or LLP member must sign
to cancel coverage — see back).
Check One
Sole Proprietor
Partner
LLC
LLP
UBI
Account ID
Business Name
Phone Number
Business Address
City
State
Zip Code
Print Applicant’s Name
Applicant’s Signature
Date
Corporate Officer Coverage as provided by RCW 51.12.110 (list name and position of all corporate
officers — see back). Please note — when you cancel coverage, you cancel coverage for all corporate
officers.
UBI
Account ID
Date
Business Name
Phone Number
Business Address
City
State
Zip Code
Print Name
Title
Signature
For State Fund Accounts, mail to:
If your Account ID starts with 700, 701, or 706, use
this address:
Department of Labor & Industries
For Self-Insured Accounts, mail to:
Employer Services
PO Box 44144
Department of Labor & Industries
Olympia WA 98504-4144
Self-Insurance Section
PO Box 44892
Questions? Call 360-902-4817
Olympia WA 98504-4892
Questions? Call 360-902-6860
F213-004-000 Cancellation of Elective Coverage 05-2018
RESET
Cancellation of Elective Coverage
Sole Proprietor/Partner, Member of Limited Liability
Company (LLC), Member of Limit Liability Partnership
(LLP), or For-Profit Corporation Officers
I, the undersigned, being either a sole proprietor, partner, member of an LLC or LLP or corporate officer of the
corporation listed below, do hereby cancel coverage.
Cancellation for corporate officers or LLCs with managers is effective 30 days after receipt of this signed
cancellation notice, or on request, provided that the requested date is at least 30 days after the written notice is
received by the department.
Cancellation for sole proprietors, partners, LLCs where management is vested in its members, or LLPs, is
effective immediately upon receipt of this signed cancellation notice. Liability for payment of premiums is
through the date of cancellation as indicated by written notification from the department.
I understand that if, as a sole proprietor, partner, member of an LLC or LLP or corporate officer(s) at a later
date, I again want the protection of the Workers’ Compensation Act, I must submit a written application to the
Department of Labor & Industries and coverage will not become effective until the day after the written
application is received by the department or a future date I request.
Owner Coverage as provided by RCW 51.32.030 (each owner, partner, LLC, or LLP member must sign
to cancel coverage — see back).
Check One
Sole Proprietor
Partner
LLC
LLP
UBI
Account ID
Business Name
Phone Number
Business Address
City
State
Zip Code
Print Applicant’s Name
Applicant’s Signature
Date
Corporate Officer Coverage as provided by RCW 51.12.110 (list name and position of all corporate
officers — see back). Please note — when you cancel coverage, you cancel coverage for all corporate
officers.
UBI
Account ID
Date
Business Name
Phone Number
Business Address
City
State
Zip Code
Print Name
Title
Signature
For State Fund Accounts, mail to:
If your Account ID starts with 700, 701, or 706, use
this address:
Department of Labor & Industries
For Self-Insured Accounts, mail to:
Employer Services
PO Box 44144
Department of Labor & Industries
Olympia WA 98504-4144
Self-Insurance Section
PO Box 44892
Questions? Call 360-902-4817
Olympia WA 98504-4892
Questions? Call 360-902-6860
F213-004-000 Cancellation of Elective Coverage 05-2018
RESET
Corporate Officers, Partners, Members of LLC or LLP
Note: Corporate Officers must be both shareholders and directors.
UBI
Account ID
Name
Signature
Position
Duties
Social Security Number
Date of Birth
% of Ownership
0.00%
Name
Signature
Position
Duties
Social Security Number
Date of Birth
% of Ownership
0.00%
Name
Signature
Position
Duties
Social Security Number
Date of Birth
% of Ownership
0.00%
Name
Signature
Position
Duties
Social Security Number
Date of Birth
% of Ownership
0.00%
Name
Signature
Position
Duties
Social Security Number
Date of Birth
% of Ownership
0.00%
Name
Signature
Position
Duties
Social Security Number
Date of Birth
% of Ownership
0.00%
Name
Signature
Position
Duties
Social Security Number
Date of Birth
% of Ownership
0.00%
Name
Signature
Position
Duties
Social Security Number
Date of Birth
% of Ownership
0.00%
F213-004-000 Cancellation of Elective Coverage 05-2018
RESET
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