The Washington Quarterly Statement of Supplemental Benefits Paid for Self Insured Employers is a financial report that employers in the state of Washington who self-insure their employees must submit to the state. This report provides an overview of the supplemental benefits that have been paid on behalf of the employer’s covered employees for the respective quarter. The report includes the name of the employer, the date of the report, the total amount of supplemental benefits paid during the quarter, and a breakdown of the benefits by type, such as medical, dental, vision, and mental health. The Washington Quarterly Statement of Supplemental Benefits Paid for Self Insured Employers is issued in two different formats: a paper form and an electronic form. The paper form must be submitted to the Washington State Department of Labor & Industries each quarter, while the electronic form must be submitted through the Washington State Department of Labor & Industries website.