| Document Received Date:
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Intent Id:
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Affidavit Id:
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Status:
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| Company Details |
| Name
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| Address |
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| WA UBI no. |
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| Contractor Registration no. |
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| Industrial Insurance Account Id
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| Email Address |
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| Filed By |
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| Prime Contractor |
| Prime contractor name |
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| Prime contractor registration no. |
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| Prime contractor Phone Number |
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| Project Information |
| Awarding agency: |
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| Awarding agency contact:
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| Awarding agency contact phone number: |
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| Contract no. |
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| Project name |
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| Project Description |
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| Dollar amount of your contract: |
$
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| Bid due date |
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| Contract award date
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| Job site address/directions: |
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| Hiring Contractor |
| Company Name |
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| Contractor Registration No. |
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| WA UBI Number |
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| Payment Details |
| Check Number: |
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| Transaction Id: |
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| Project Details |
| County where work was performed |
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| City where work was performed |
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| Prime contractor Intent form Id# for this project |
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| Intent filed date |
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| Job start date:MM-DD-YYYY |
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| Date work completed:MM-DD-YYYY |
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| Project Completion |
| Did your company hire any subcontractors? |
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| Did your company have employees perform work on this project? |
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| Did you use apprentice employees on this project? |
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| Is the prime contract at a cost of over one million dollars ($1,000,000)?
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| Company Owner Information |
| How many owner/operators performed work on the project that own 30% or more of the company?
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| Affidavit Subcontractor(s) |
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| Journeylevel Wages |
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| Apprentice Wages |
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