CompWise Retro - RFP

Find out how you can benefit from AWB CompWise today!
Please send me a no-obligation proposal showing my company’s refund potential!

No Obligation Proposal Request Form
(Please print form, fill out and fax back to AWB)

Contact Name_________________________________________

Title_________________________________________________

Company_____________________________________________

Address______________________________________________

City, State, Zip_________________________________________

Phone (_____)______________ FAX (_____)_______________

Email________________________________________________

Number of employees in Washington state ___________________

UBI Number___________________________________________

L&I Number___________________________________________

- Sub accounts (if applicable)_____________________________

• Are you currently enrolled in another Retro program? __Yes __No
  • If yes, what month is your enrollment anniversary?
    __ January? __ April? __ July? __ October?
    

I authorize the Department of Labor & Industries to release claims history and premium information on the above account to the Association of Washington Business and its designated representatives.

Signature:_____________________________________ Date: ________

Request Form Steps:

1. Print out this form;
2. Completely fill out form and sign
3. FAX completed form to: (360) 943-5811

Or, MAIL completed and signed form to:
Association of Washington Business
PO Box 658
Olympia, WA 98507-0658

Or, Contact Jennifer Costello: 1-800-521-9325