Workmen's compensation and industrial insurance under modern conditions v. 1

accept each and all of the provisions of the Industrial Insurance Act of the State of Washington (Chapter 74, Session Laws of 1911), and do hereby subject ourselves irrevocably and completely to all of the provisions of said law, to all intents and purposes as if we had been originally included within its terms.

In Witness Whereof, We have hereunto set our hands, this ---day of‒‒‒‒‒‒‒‒‒‒, 19-

Employer.

Employés of said employer. Witnessed by

Employés of said employer.

The above election and adoption is hereby approved this----day of------, 19---

INDUSTRIAL INSURANCE COMMISSION.

(ELECTIVE ADOPTION OF ACT) (Sec. 19, Chap. 74, Session Laws of 1911). "Any employer and his employés engaged in works not extra hazardous, may by their joint election, filed with the department, accept the provisions of this act, and such acceptances, when approved by the department, shall subject them irrevocably to the provisions of this act to all intents and purposes as if they had been originally included in its terms. Ninety per cent. of the minimum rate specified in section 4 shall be applicable to such case until otherwise provided by law."

§ 138. Form of demand for first quarterly payment required by act (f):

To the Industrial Insurance Commission, Dr.

Olympia, Washington.

As required by law, demand is hereby made upon you for the payment of $__ the same representing your first or preliminary payment into the "Accident Fund" created by the Workmen's Compensation Law (Ch. 74, Session Laws of 1911), and is based upon data and payrolls for the months of

heretofore received from you by this office.

and

This first payment covers your

(19

and

-) payrolls. At the end of each year an adjustment will be made upon the basis of the actual payroll for the year, and your

contributions as required by the law will be based upon your actual yearly payroll.

This first quarterly payment will be sufficient until such time as the accidents occurring in your particular class have depleted the fund to such an extent that further payments are required.

Under Section 4 of the law, the first payment, herein and hereby demanded, must be received in this office on or before‒‒‒‒‒‒‒‒‒‒‒‒; otherwise, you will be in default and subject to the serious perils and penalties of Section 8, of the act relating to "defaulting employers."

This notice to you is a "demand for payment" as prescribed in Section 8 of said law. No further demand will be made upon you for this first quarterly payment, and prompt attention, therefore, is extremely important.

Yours very truly,

Industrial Insurance Commission.
By....

Chairman.

Attest:

The amount herein demanded as the first quarterly payment is the true and correct amount under the law, and has been computed on the basis of data and payrolls of the above firm, heretofore submitted and on file in this office.

Chief Auditor, Industrial Insurance Commission.

§ 139. Form of monthly statement (g):

The following report is made to the INDUSTRIAL INSURANCE COMMISSION of the State of Washington, showing names and payrolls of all contractors engaged in public work during the month of-----------, for the City of-------- County of-----

Signed by
Official Title

§ 140. Alphabetical list of industries with rates and classification (h).-The following is an alphabetical list of the industries comprehended in the act, together with the rate of contributions that they bear, and the class in which they are placed: