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Application For Inclusion On List Of Eligible Attorneys F249-017-000 - Washington

Application For Inclusion On List Of Eligible Attorneys Form. This is a Washington form and can be used in Third Party - Subrogation Workers Comp .
 Fillable pdf Last Modified 10/24/2011
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Department of Labor and Industries Worker's Compensation Special Assistant Attorney General Program Third Party Section P.O. Box 44288, Olympia, WA 98504-4288 Name: Firm: Address: City: State: Phone: ( ) APPLICATION FOR INCLUSION ON LIST OF ELIGIBLE ATTORNEYS FAX: ( ) Zip: Active Member of State Bar Association No No Yes Yes WSBA Number: ___________________________ Account Number: ___________________________ I have an attorney trust account that complies with the Washington Rules of Professional Conduct. Name of Bank or Institution: ___________________________________________________________________________ I have in force Professional Liability Insurance? No Yes Insurance Carrier: ___________________________________ Policy Number: ________________________________ States Licensed In: Areas of Emphasis in Tort Law: (Optional) Counties where willing to practice: Accept cases with L&I claim costs: under $1,000 $1,000 - $5,000 over $5,000 I agree to inform the Department of Labor and Industries of any changes to my qualification as stated above. I recognize that this application, and inclusion on the list, does not give me any right to or expectation of employment as a Special Assistant Attorney General. I declare under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct. Signature: ____________________________________________ Date: _________________________________________________ UBI #: SS# or Fed ID #: L&I Account #: Please duplicate for your records and mail original to: Department of Labor and Industries Workers Compensation Special AAG Program Third Party Section PO Box 44288, Olympia WA 98504-4288 (360) 902-5100 F249-017-000 Application for Inclusion Eligible Attorney 8-2011 American LegalNet, Inc. www.FormsWorkFlow.com
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