Electronic Signature- Washington Temporary Authorization Form

State of Washington authorization form

Department of Labor and Industries

P.O. Box 44180

Olympia, WA 98504-4180

Date*

Please release all historical workers' compensation claims and premium data to Sedgwick UBI 601 767 420, and its representatives, for the following company:

Firm name*

Account ID*

This authorization includes access to the Claim and Account Center (CAC) to review all premium paid, hours reported, claims charged to the account(s).

Thank you for your assistance.

Sincerely,

Name (print)*

Signature*

Electronic signature notice: By typing your name in this box, you are agree to the terms of the authorization form.

Title*

Phone*

Phone

Email*

Check this box to receive a copy of the authorization for your records.

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