Application for Group Retrospective Rating

Document Information
  How to complete a fillable form.
Title Application for Group Retrospective Rating (English)
Document number F250-004-000
Document type Form
How to get this document
  • Call L&I's Retrospective Rating Program, 360-902-4851. Please have the document number ready so we can process your request quickly. The title is also helpful.

  • Check for alternate languages of this document
    Valid dates 08/2017
    Contact information Contact Us About Retrospective Rating
    Related information
    Documents Application for Group Membership & Authorization for Release of Insurance Data
    Websites Qualify for Refunds

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