Interest/Release Form | Approach Management Services

Submit the form below and we’ll request your account history from L&I. We’ll be in touch in just a few days with a detailed analysis tailored to your company.

Retro interest form

Contact information
Company Name*
Contact Person*
First Last
Email*
Phone*
More info*
By providing your L&I number now, an Approach representative will research your premium-and-loss history to determine if you qualify. Would you like to do this now?
- Yes
- No

Information release
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
L&I Account ID
(8-digits, numbers only)
Are you currently a member of a Retro program?
- Yes
- No
Which Retro Program?
Authorization is hereby given to the Washington State Department of Labor and Industries to provide all information pertaining to the industrial insurance account listed above, including all related active or inactive sub accounts to Approach (or its designate). This includes access to the Claims and Account Center for a period of six months after signature date. I understand that this information will be used solely to assess my potential eligibility for participation in a Group Retrospective Rating plan. I understand that a copy of this release constitutes an original. This authorization is effective immediately and granted from the date of the signature or until withdrawn through our written notification to the department or Approach.
Signature
Please use your mouse or finger to sign in the box
Date
Date Format: MM slash DD slash YYYY

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Retro interest form

Contact information

Information release