Policyholder workers' compensation employer's quarterly report wa uni˜ed business identi˜er (ubi): l&i account id: due date: report is fo rquarte :
* use with form f212- 055-000 use the late payment worksheet on and interest instructions. step important: if your business currently has optional workers'...
f212-055-000 qr 9/05signature - information report prepared by (print name) preparer's telephone number official position ideclare under the penalty of perjury of...