Application For Inclusion On List Of Eligible Attorneys {F249-017-000}

Mail Original Form to: Department of Labor and Industries Special Assistant Attorney General Program Third Party Section PO Box 44288, Olympia, WA 98504-4288 Name: Firm: Address: City: State: Phone #: Application for Inclusion on List of Eligible Attorneys Fax #: Email address: Zip: Active member of State Bar Association: No Yes WSBA number: I have an attorney trust account that complies with the Washington Rules of Professional Conduct. No Yes Name of Bank or Institution: I have in force professional liability insurance. Insurance carrier: Other States licensed in (Bar # for other states): Areas of emphasis in Tort Law: Product Liability Construction MVA Aircraft Premise Liability Medical Malpractice Asbestos Legal Malpractice Slip/Fall No Account number: Yes Policy number: Other languages spoken fluently: Counties where you are willing to practice: Accept cases with L&I claim costs: under $1,000 $1,000 - $5,000 over $5,000 I agree to inform the Department of Labor and Industries of any changes to my qualification as stated above. I recognize that this application, and inclusion on the list, does not give me any right to or expectation of employment as a Special Assistant Attorney General. In the event any potential conflict of interest arises, the attorney must notify the Department in writing of the existence and nature of the potential conflict within 20 calendar days. I declare under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct. Signature: Date: UBI #: SS# or Fed ID #: L&I Account #: F249-017-000 Application for Inclusion Eligible Attorney 08-2016 American LegalNet, Inc. www.FormsWorkFlow.com