Form F250-016-000 "Application for Group Membership and Authorization for Release of Insurance Data" - Washington

What Is Form F250-016-000?

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 April 1, 2012;
  • 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;

Download a fillable version of Form F250-016-000 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 F250-016-000 "Application for Group Membership and Authorization for Release of Insurance Data" - Washington

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Department of Labor and Industries
APPLICATION FOR GROUP MEMBERSHIP
Retrospective Rating Program
|
AND AUTHORIZATION FOR RELEASE OF INSURANCE DATA
retro@Lni.wa.gov
www.retro.Lni.wa.gov
Mail to association:
Retro ID
UBI
Account ID
Application Deadline
Employer
Coverage Year Beginning
If you have more than one L&I industrial insurance account you must enroll all sub accounts that are of a similar business
nature. You may elect to enroll all dissimilar businesses.
RESET
If you want to enroll dissimilar businesses, please check the sub account box.
If you have questions about this requirement please contact the business association listed above or L&I at (360) 902-4851.
As a member of the sponsoring organization listed above, this employer applies for enrollment in the retrospective
rating group sponsored by the organization. L&I will notify the sponsoring organization of acceptance or denial of
your application to participate in the group. It is the responsibility of the sponsoring organization to notify you of this
acceptance or denial. As a pre-requisite of enrollment each of your industrial insurance accounts must be in good
standing at the time of enrollment or you will not be allowed to participate in retrospective rating.
By signing this application, the employer named above agrees with all of the following conditions:
• L&I will automatically re-enroll the employer as a member of the group in future coverage periods provided the
employer’s industrial insurance account is in good standing at the time of re-enrollment. If the employer does not want to
participate in future coverage periods the employer or sponsoring organization must notify L&I in writing prior to the
beginning of the respective coverage period.
• The employer authorizes L&I to furnish the sponsoring organization or their designee with data and information obtained
from the employer’s industrial insurance account(s).
• The sponsoring organization will represent the employer in all matters applicable to retrospective rating participation and
the employer’s industrial insurance account(s).
• The employer agrees to comply with L&I rules, regulations and laws and is bound by the terms of the agreement between
the sponsoring organization and L&I.
• The employer will cooperate with L&I claims management activities and will participate in the sponsoring organization’s
claims management and workplace safety initiatives.
• All retrospective rating adjustments that may be earned by the employer will be given to the sponsoring organization. L&I
is not involved in the distribution of a group refund to the individual group members except in the case of defunct group.
These conditions are in effect immediately and will remain in effect through the term of any agreement between the sponsoring
organization and L&I.
NOTE: L&I disclaims any interest in any other contract you may enter into with the sponsoring organization as their pre-
requisite of your participation in the retrospective rating group that they sponsor, and L&I neither approves or disapproves of
any language or provision contained in these other contracts.
RETURN this application directly to the above organization.
DO NOT send this application directly to L&I.
Signature of an owner, partner or corporate officer of the employer named above is required to participate in
this retrospective rating group.
Type or print name
Title
Date
Owner, partner, corporate officer
Signature
Index: APM
F250-016-000 app for group membership and authorization for release of insurance data 04–2012
Department of Labor and Industries
APPLICATION FOR GROUP MEMBERSHIP
Retrospective Rating Program
|
AND AUTHORIZATION FOR RELEASE OF INSURANCE DATA
retro@Lni.wa.gov
www.retro.Lni.wa.gov
Mail to association:
Retro ID
UBI
Account ID
Application Deadline
Employer
Coverage Year Beginning
If you have more than one L&I industrial insurance account you must enroll all sub accounts that are of a similar business
nature. You may elect to enroll all dissimilar businesses.
RESET
If you want to enroll dissimilar businesses, please check the sub account box.
If you have questions about this requirement please contact the business association listed above or L&I at (360) 902-4851.
As a member of the sponsoring organization listed above, this employer applies for enrollment in the retrospective
rating group sponsored by the organization. L&I will notify the sponsoring organization of acceptance or denial of
your application to participate in the group. It is the responsibility of the sponsoring organization to notify you of this
acceptance or denial. As a pre-requisite of enrollment each of your industrial insurance accounts must be in good
standing at the time of enrollment or you will not be allowed to participate in retrospective rating.
By signing this application, the employer named above agrees with all of the following conditions:
• L&I will automatically re-enroll the employer as a member of the group in future coverage periods provided the
employer’s industrial insurance account is in good standing at the time of re-enrollment. If the employer does not want to
participate in future coverage periods the employer or sponsoring organization must notify L&I in writing prior to the
beginning of the respective coverage period.
• The employer authorizes L&I to furnish the sponsoring organization or their designee with data and information obtained
from the employer’s industrial insurance account(s).
• The sponsoring organization will represent the employer in all matters applicable to retrospective rating participation and
the employer’s industrial insurance account(s).
• The employer agrees to comply with L&I rules, regulations and laws and is bound by the terms of the agreement between
the sponsoring organization and L&I.
• The employer will cooperate with L&I claims management activities and will participate in the sponsoring organization’s
claims management and workplace safety initiatives.
• All retrospective rating adjustments that may be earned by the employer will be given to the sponsoring organization. L&I
is not involved in the distribution of a group refund to the individual group members except in the case of defunct group.
These conditions are in effect immediately and will remain in effect through the term of any agreement between the sponsoring
organization and L&I.
NOTE: L&I disclaims any interest in any other contract you may enter into with the sponsoring organization as their pre-
requisite of your participation in the retrospective rating group that they sponsor, and L&I neither approves or disapproves of
any language or provision contained in these other contracts.
RETURN this application directly to the above organization.
DO NOT send this application directly to L&I.
Signature of an owner, partner or corporate officer of the employer named above is required to participate in
this retrospective rating group.
Type or print name
Title
Date
Owner, partner, corporate officer
Signature
Index: APM
F250-016-000 app for group membership and authorization for release of insurance data 04–2012