Form F212 233 Ooo PDF Details

The F212 233 Ooo form serves as a vital tool for Washington businesses managing workers compensation for employees operating outside of the state. Drafted by the Department of Labor & Industries, it stands as an Employer’s Supplemental Quarterly Report tailored for workers' compensation, emphasizing that no premiums are due with this submission. The document delineates a precise procedure for businesses that have not yet applied for out-of-state reporting or those yet to provide a copy of their out-of-state workers' compensation insurance certificate, directing them to make a crucial call to the specified contact number. It encapsulates key details including the business name, main office address, and out-of-state information such as the state or country where the employee(s) started work, alongside the total days worked. Notably, the form demands accuracy and truthfulness under the penalty of perjury as per the laws of the state of Washington. Additionally, it requires a detailed listing of Washington workers with out-of-state hours, complemented by a classification addendum for a comprehensive outline of the work performed. This framework not only ensures compliance but also fosters a structured reporting mechanism for employers navigating the complexities of workers' compensation for out-of-state employment.

QuestionAnswer
Form NameForm F212 233 Ooo
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other names212233af washington form f212 mailing address

Form Preview Example

Page 1 of 4

Department of Labor & Industries

Washington Workers Insured Out of State:

Insurance Services

Employer’s Supplemental Quarterly

 

Report for Workers’ Compensation

 

No Premiums are due with this report

Note: If you haven’t applied for out-of-state reporting and provided us with a copy of your out-of-state workers’ compensation insurance certificate, please call (360)-902-5564. This needs to be completed prior to submitting this report.

Business name

Main office address

City

State

ZIP

Out-Of-State Information

 

 

 

 

 

State or Province

Country

 

 

 

 

 

For above state, province or country:

 

 

 

 

 

Date employee(s) began work:

 

 

 

 

 

Has work ended? No Yes

 

 

 

 

 

Total full or partial days worked

 

If yes, date work ended:

 

this year, in this state, province,

 

 

 

 

 

or country :

 

 

 

 

 

 

Out-of-state workers comp policy effective date:

 

 

 

 

 

If you qualify for out-of-state supplemental reporting in MORE THAN ONE state, complete a separate report for each state, province or country.

UBI Number

Account ID

This report is for quarter ending

Due Date

Date out-of-state coverage will or has ended:

CLASS

CLASSIFICATION DESCRIPTION

GROSS PAYROLL

HRS/UNITS

Use addendum sheets as needed.

SIGNATURE – INFORMATION

I declare under the penalty of perjury of the laws of the state of Washington (RCW 9A.72.020) that the information contained in this report and in any attachment is true and correct.

Sign here X

Print name here

Check type of organization

 

Corp.

LLC Individual Partnership Other

 

 

Official Position

Employer’s Telephone Number

 

 

 

Preparer’s Telephone number

Date

Report Prepared By

F212-233-OOO employer’s quarterly report of out of state work by Washington workers insured outside of Washington 11-2008

Page 2 of 4

List Washington workers with out-of-state hours/units included in this report.

FIRST NAME

MI

LAST NAME

SOCIAL SECURITY NUMBER

Use addendum sheets as needed.

SEND TO THIS ADDRESS:

Dept of Labor & Industries

PO Box 24688

Seattle WA 98124-0688

F212-233-OOO employer’s quarterly report of out of state work by Washington workers insured outside of Washington 11-2008

Page 3 of 4

Classification Addendum for Out-of-State Supplemental Report

Business Name

 

 

UBI Number

 

Out-Of-State Information

 

 

 

 

Account ID

 

 

 

 

 

 

 

 

State or Province

Country

This report is for

 

 

 

Quarter Ending

 

 

 

 

 

CLASS

CLASSIFICATION DESCRIPTION

GROSS PAYROLL

HRS/UNITS

F212-233-OOO employer’s quarterly report of out of state work by Washington workers insured outside of Washington 11-2008

Page 4 of 4

Addendum Name List for Out-of-State Supplemental Report

Business Name

 

 

UBI Number

 

Out-Of-State Information

 

 

 

 

Account ID

 

 

 

 

 

 

 

 

State or Province

Country

This report is for

 

 

 

Quarter Ending

 

 

 

 

 

FIRST NAME

MI

LAST NAME

SOCIAL SECURITY NUMBER

F212-233-OOO employer’s quarterly report of out of state work by Washington workers insured outside of Washington 11-2008

How to Edit Form F212 233 Ooo Online for Free

Should you desire to fill out Form F212 233 Ooo, you don't have to download any applications - simply try our PDF tool. In order to make our tool better and easier to utilize, we consistently work on new features, bearing in mind suggestions from our users. Starting is simple! All you have to do is stick to the following simple steps below:

Step 1: Simply click the "Get Form Button" above on this page to start up our form editor. There you'll find everything that is necessary to work with your document.

Step 2: As soon as you launch the online editor, there'll be the form ready to be filled in. Apart from filling out different blank fields, it's also possible to perform various other things with the PDF, such as putting on custom textual content, modifying the original textual content, inserting illustrations or photos, putting your signature on the PDF, and more.

This document needs some specific information; to ensure correctness, please make sure to take note of the tips hereunder:

1. While submitting the Form F212 233 Ooo, be sure to complete all necessary blanks within the relevant section. This will help speed up the process, enabling your details to be handled fast and appropriately.

Filling out segment 1 of Form F212 233 Ooo

2. After filling in the previous step, go to the next part and fill out the necessary particulars in all these fields - CLASS, CLASSIFICATION DESCRIPTION, GROSS PAYROLL, HRSUNITS, Use addendum sheets as needed, SIGNATURE INFORMATION, I declare under the penalty of, Check type of organization, Individual, Partnership, Other, Corp, LLC, Official Position, and Employers Telephone Number.

Tips to fill in Form F212 233 Ooo stage 2

3. The third stage will be hassle-free - complete all of the form fields in FIRST NAME, LAST NAME, and SOCIAL SECURITY NUMBER to conclude the current step.

FIRST NAME, SOCIAL SECURITY NUMBER, and LAST NAME in Form F212 233 Ooo

4. Completing SEND TO THIS ADDRESS Dept of Labor, and Use addendum sheets as needed is crucial in the next section - don't forget to take the time and take a close look at every single blank area!

How one can complete Form F212 233 Ooo part 4

5. And finally, this last subsection is what you should wrap up before submitting the PDF. The blank fields in question are the following: Classification Addendum for, Business Name, OutOfState Information State or, Country, UBI Number, Account ID, This report is for Quarter Ending, CLASSIFICATION DESCRIPTION, GROSS PAYROLL, CLASS, and HRSUNITS.

Form F212 233 Ooo writing process explained (stage 5)

People who use this document generally make mistakes when completing GROSS PAYROLL in this section. Be certain to reread whatever you type in right here.

Step 3: Glance through all the information you've inserted in the blanks and hit the "Done" button. Grab your Form F212 233 Ooo the instant you sign up at FormsPal for a 7-day free trial. Immediately gain access to the form from your personal cabinet, along with any edits and adjustments being conveniently synced! FormsPal guarantees your data confidentiality by having a secure system that in no way records or distributes any type of personal data used. Feel safe knowing your paperwork are kept protected when you work with our services!

Form F212 233 Ooo isn’t the one you’re looking for?

Related Documents