Order Report of Accident (ROA) forms

For providers only. Use this online form to order Report of Industrial Injury or Occupational Disease (Report of Accident) paper forms.

Warehouse Order Request

Order Form
Form Title	# of forms needed
Report of Industrial Injury or Occupational Disease (Report of Accident) (English) F242-130-000:
Instructions in Spanish for completing the Report of Industrial Injury or Occupational Disease (Report of Accident) (Spanish) F242-130-999:
Mail forms to:	* indicates required field
*  Contact name :	Please enter a contact name.
*  Business name :	Please enter the business name.
*  Mailing address :	Please enter the mailing address.
Mailing address (cont.) :
*  City, State, and Zip:	Please enter the city. AA AE AK AL AP AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VI VT WA WI WV WY Please enter the zip code.
*  Contact phone (000‑000‑0000) :	Please enter the phone number.
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Customers located within the United States can use the form below to order ROA forms. Others should send their request by e-mail to whsemail@lni.wa.gov. Please do not call the warehouse to order this form.