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SERVICE PROVIDER: Please fill in the spaces and sign in the box appropriate for <br /> your business entity. <br /> Corporation //!! -�^ <br /> l..vrVe 1 F n+er .-c i s e Co ,. l Inc-, <br /> [Service Pr vider's Complete Legal Name] <br /> By: � <br /> Typed/P 'nted amI._fNLhS• C'/YA/[l►�1 <br /> Its: C v <br /> Date: 2..).-Co — (8 <br /> Partnership <br /> (general) [Service Provider's Complete Legal Name] <br /> a Washington general partnership <br /> By: <br /> Typed/Printed Name: <br /> General Partner <br /> Date: <br /> Partnership <br /> (limited) [Service Provider's Complete Legal Name] <br /> a Washington limited partnership <br /> By: <br /> Typed/Printed Name: <br /> General Partner <br /> Date: <br /> Sole <br /> Proprietorship Typed/Printed Name: <br /> Sole Proprietor: <br /> Date: <br /> Limited <br /> Liability [Service Provider's Complete Legal Name] <br /> Company a Washington limited liability company <br /> By: <br /> Typed/Printed Name: <br /> Managing Member <br /> Date: <br /> Page 11 <br /> Workers Compensation PSA 2018 <br />