Vancouver Chamber of Commerce

Fields marked (*) are required

Company Name:*
Contact Person:*
Address:
City:
State:
Zip:
Phone: *
E-mail:*
L & I Account ID#:
Approx. # years under this ID#:
Approx. # of Employees:
Approx. Annual L & I Premiums:
To the Department of Labor & Industries: You are hereby authorized to release to the Greater Vancouver Chamber of Commerce information regarding premiums and claims history on the account listed.
Name:
Title:
Date:

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