WSDA Retro Application

Complete the following application to enroll in the free, members-only WSDA Retro program.

Please note that application responses will be delayed from June 26-July 4. Applications received during this time will receive the required final e-signature form on Monday, July 7. Thank you!

Participant Information

Primary Owner Dentist First Name

Primary Owner Dentist Last Name

Primary Owner Dentist ADA Number

Primary Owner Dentist Email

Primary Owner Dentist Phone

Please list the names and ADA numbers for all additional owner dentists, if applicable.

Practice Information

Business/Employer Name

DBA (If Applicable)

Street Address

City

State

ZIP

UBI and L&I Numbers

The application requires your UBI and L&I account number. You can search for both using this tool from L&I.

Search UBI and L&I Numbers

Unified Business Number (UBI)

L&I Account Number

Claims Contact Information

Select a choice

If claims contact is same as primary owner, check here and skip.

Name

Title

Phone

Acknowledgment of Participation Agreement

As an applicant to participate in WSDA Retro, I hereby acknowledge and agree to the terms and conditions as set forth in the Group Retrospective Rating Program Participation Agreement. Click here to read the agreement.

Check this box to agree to the participation agreement.

I Agree

How to Complete Your Application

Applicants must e-sign a required Department of Labor & Industries (L&I) form to finalize their WSDA Retro application. Please review the following steps before pressing submit.

Within 1-2 business days of submitting this form, you will receive an email from Emma Brown via Adobe Acrobat Sign (adobesign@adobesign.com).
Click "Review and Sign" to e-sign this required L&I form.
Once you have e-signed the form, your application will be complete.