Washington State Form F212-055-000 - Quarterly Report for Industrial Insurance

Greg Hatfield Updated by Greg Hatfield

Instructions (F212-239-000, 08-2009)

IMPORTANT: If your business currently has optional workers' compensation coverage for owners, partners, corporate officers, or LLC members, include these hours in your calculation.


A - Enter in Column 3 the total gross payroll for all workers in the appropriate class code.

B - Enter in Column 4 the total worker hours for the quarter in each class code.

C - Multiply the total hours worked in each class code by the rate in Column 5.

D - Write the premium owed for each class code in Column 6.


Enter your subtotal in Box 7 and add any other charges.

When your report is ready, send it to us with your check made out to L&I, using the enclosed envelope. Make a copy for yourself.

No employees this quarter?

Write “no workers” on the form and send by the due date. This is the only way we will know you do not owe a payment for the quarter. If the report is not postmarked by the due date, we will charge a $10 late fee.

When completed reports and payments are due to L&I.

Calendar quarter:

Report must be postmarked by:

Jan. 1 – March 31

April 30

April 1 - June 30

July 31

July 1 - Sept. 30

Oct. 31

Oct. 1 – Dec. 31

Jan. 31

Due date fall on a weekend? Your report may be postmarked the following business day.

Need Help?

Call your account manager. The name and number is at the top of your enclosed Quarterly Report.

Business information changed? Complete the back of the Quarterly Report.

Want to pay online next time? Go to: quarterlyreports.LNI.wa.gov. Use your PAC number on the top left corner of your Quarterly Report.

How did we do?

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Washington State Forms 5208A and 5208B, Employer's Quarterly Tax and Wage Detail Reports