| Number |
Title |
| BLS 700-028 |
Minor Work Permit (Master Business Application)
Link is to the Dept. of Licensing online form: Required for employers who hire minors and is obtained by completing the Master Business Application. Also available from L&I warehouse. |
| F100-002-000 |
Apprentice Work Progress Record
Worksheets used to record the number of hours worked and Related Supplemental Instruction hours during a registered apprenticeship on a monthly basis. If used, a copy is usually given to the program monthly. |
| F100-012-000 |
Program Equal Employment Opportunity Activity Documentation
Used to record individual equal employment opportunity activities conducted by Apprenticeship Programs. |
| F100-016-000 |
Apprenticeship Agreement
Used by the registered apprenticeship progam to setup an agreement with the apprentice. |
| F100-019-000 |
On-the-Job Training Agreement Card
This card is used by an OJT Apprenticeship program ONLY. To recieve this form, you must contact the Apprenticeship Section. |
| F100-021-000 |
Request for Change of Status - Apprenticeship/Training Agreements and Training Agents
Used to request a change of status for apprentices, the training agreements or the training agents. These are normally accompanied by Committee meeting minutes when submitted. |
| F100-022-000 |
The Apprenticeship Advantage: Earn While You Learn!
Fact sheet: Introduces apprenticeship to younger people. Explains the benefits of apprenticeship, a program of study where apprentices earn wages while learning a skilled profession. Includes contact information for L&I's apprenticeship coordinators around the state. |
| F100-024-000 |
Suggested Procedure for Apprenticeship Committee Meetings
Suggestions on how to have successful apprenticeship committee meetings. |
| F100-029-000 |
Minutes of Apprenticeship Committee Meeting
Example of how the minutes for an Apprenticeship Committee meeting should be recorded. Submit this to L&I Apprenticeship section within 30 days of the meeting. |
| F100-030-000 |
Request for Revision of Standards
Used to request a revision of standards except for committee members. |
| F100-031-000 |
Request for Revision of Committee
Used to request revision of committees to include changing the title of the standards, sub-committees, and training directors/coordinators. |
| F100-033-000 |
Application for Apprenticeship
EXAMPLE ONLY: Example of an application to apply for an apprenticeship. Registered Apprenticeship Programs use their own forms. NOT TO BE USED TO REQUEST PLUMBER or ELECTRICAL TRAINEE CARD. |
| F100-041-000 |
Washington State Apprenticeship Programs Catalog
Book: Provides an overview of apprenticeship, explains general requirements, lists the apprenticeship programs in Washington Stateand, and provides contact information. The version available online may contain more up-to-date information than the May 2009 printed edition. |
| F100-045-000 |
Apprenticeship Applicant Register
Example: Used for tracking applicants for an apprenticeship program. Registered Apprenticeship Programs use their own forms. |
| F100-049-000 |
Request for New Standards
Request for new apprenticeship standards. |
| F100-050-000 |
Journey Level Wage Rate from which apprentices' wages rates are computed.
Used to submitted the Journey-level wage rate from which the apprentices' wage rate is computed. Form must be submitteed at least annually or sooner if the rates change. |
| F100-228-000 |
Related Supplemental Instruction Hours
Used by Apprenticeship programs to submit related instruction hours to L&I Apprenticeship section. It is preferred that programs use the combined RSI/OJT reporting form. RSI Hours must be reported quarterly. |
| F100-229-000 |
On-The-Job Training Work Hours
Used to report the work hours for an on-the-job training employee. |
| F100-303-000 |
Request for Cancellation of Program
Used for cancelling an apprenticeship program. |
| F100-500-000 |
Authorization of Signature
This gives individuals other than the Secretary or Chairman authorization to sign ALL Papers or just Registration Cards. Must be signed by a quorum of the Apprenticeship Committee. |
| F100-503-000 |
Apprenticeship Transfer Agreement
Used to allow an apprentice to transfer from a Washington State Registered apprenticeship program to another Washington State Registered program. |
| F100-504-000 |
Request for New Apprenticeship Committee
Used to establish a new apprenticeship committee and list it's employer/employee representatives. |
| F100-505-000 |
Apprenticeship Complaint (Not for Apprenticeship Appeals)
Used to file a complaint on a apprenticeship program, committee, training agent, etc.
NOT be used by Apprentices appealing Committee Decisions. |
| F100-508-000 |
Approved Training Agent
Used to allow an employer to train apprentices as part of a Registered Apprenticeship program. |
| F100-509-000 |
Instructor's Report of Accident / Incident
This form must be submitted to L&I's Apprenticeship Section by the Instructor at the time of the incident and the appropriate Apprenticeship Program within 5 days of an accident/incident of an apprentice/trainee during Related Supplemental Intruction (RSI). |
| F100-510-000 |
Request for Cancellation of New Apprenticeship Committee
To request a cancellation of a new apprenticeship committee which never has a "Request for New Standards" approved by the WSATC |
| F100-511-000 |
Notice to Attending Physician of Apprentice / On-the-Job-Training Accident / Incident
A notice to the attending physician that the individual is a Registered Apprentice and to attach this form to the Accident Report of Industry Injury or Occupational Disease (F242-130-000). |
| F100-512-000 |
Registered Apprenticeship Program Address/Mailing Information Update
Used by the Registered Apprenticeship Program to update their address or mailing information. (Note: This does update your program standards information.) |
| F100-513-000 |
Equal Employment Opportunity (EEO) Resource & Referral Update Form
Used by an organization to get on the Apprenticeship Program equal opportunity resources list or use to update their information on the list. |
| F100-515-000 |
Log of Good Faith Effort Documentation
This is for Registered Apprenticeship Programs to record Good Faith Effort activities in accordance with their Registered Apprenticeship Standards (Equal Employment Opportunity Plan) |
| F100-516-000 |
Notice of Contest or Objection to Proposed Standards of Apprenticeship
Used by competitor to contest or object to a proposed standards of apprenticeship, new occupation or revised geographical area. Submit this form at least 20 days prior to a Council meeting. |
| F100-517-000 |
NOTICE - Your Right to Register Equal Employment Opportunity (EEO) Complaints
This notice is to be posted by Apprenticeship Programs in plain view to inform apprentices or apprenticeship applicants of who to contact in regards to EEO Complaints. |
| F100-518-000 |
Related Supplemental Instruction / On-the-Job Training Hours
Used to track apprentices/trainees on-the-job training hours. |
| F100-519-000 |
Apprenticeship Related Supplemental Instruction Plan Review Glossary of Terms
Glossary of terms used with Apprenticeship Related Supplemental Instruction (RSI) Plan Review form amd RSI Plan. |
| F100-520-000 |
Apprenticeship Related Supplemental Instruction (RSI) Plan Review
Used by apprenticeship programs/sponsors as part of the process of getting new programs/standards/occupations approved. |
| F100-521-000 |
Process for Developing and Approving Related Supplemental Instruction (RSI)
Describes the process for getting approval of new or revised RSI for new apprenticeship programs/standards/occupations. |
| F100-522-000 |
Standards of Apprenticeship
Blank form for creating Registered Apprenticeship Standards. This document is used to create Apprenticeship Standards which will go before the Washington State Apprenticeship and Training Council for approval. |
| F100-523-000 |
Training Agent Agreement and Understanding of Equal Employment Opportunity (EEO) Requirements of the Apprenticeship Commmittee - Alternate Selection Process
This should be signed by all employers who are Training Agents with Apprenticeship Programs that use an Alternate Selection Process. This also explains their obligations and rights as part of this process. |
| F100-526-000 |
Apprenticeship Advantage poster
Poster: Introduces apprenticeship, especially for younger people. Promotes the benefits of apprenticeship and includes contact information to learn more. |
| F101-002-000 |
Employers' Guide to Industrial Insurance
Book: Explains the basic requirements of Washington's industrial insurance law. Suggests ways to protect workers' safety and health and minimize industrial insurance costs. Includes sample forms and L&I telephone numbers. |
| F101-009-000 |
Request for Public Records
To request public records from Washington State Dept. of Labor and Industries. |
| F101-010-000 |
Authorization to Release Claim Information
Used by the worker to designate a person(s) as an authorized representative for the worker's claim. An authorized representative can access claim information. |
| F101-010-111 |
Request for Claim Information
Used by workers, workers' representatives, employers or employers' representatives to request claim information from L&I. |
| F101-010-999 |
Autorización Para Proveer Información De Reclamos
Used by the worker to designate a person(s) as an authorized representative for the worker's claim. An authorized representative can access claim information. |
| F101-054-000 |
Workplace Posters: Required and Recommended
Fact sheet: Lists the posters L&I and other state and federal agencies require employers to post in their places of business. Several recommended posters are listed as well. The URLs for posters available online and and telephone numbers to request printed posters are also provided. See also L&I Workplace Posters: Required and Recommended. |
| F101-055-909 |
Your Privacy Is Important to Us (English/Spanish)
Fact sheet: Serves as L&I's official privacy notice. States how L&I may use and share the pesonal information it collects. It also informs the public how they can file a complaint if they believe L&I has misused or inappropriately disclosed their personal information. |
| F101-060-000 |
Web Advertising Card
Flier: Promotes L&I's web site and lists the URLs for online services. |
| F101-061-404 |
What Are Your Rights as a Worker? (English/Russian)
Fact sheet: Provides a brief overview of the worker rights administered by the Department of Labor and Industries. These include certain employment-related rights and rights pertaining to workplace safety and workers' compensation benefits. |
| F101-061-505 |
What Are Your Rights as a Worker? (English/Vietnamese)
Fact sheet: Provides a brief overview of the worker rights administered by the Department of Labor and Industries. These include certain employment-related rights and rights pertaining to workplace safety and workers' compensation benefits. |
| F101-061-606 |
What Are Your Rights as a Worker? (English/Cambodian)
Fact sheet: Provides a brief overview of the worker rights administered by the Department of Labor and Industries. These include certain employment-related rights and rights pertaining to workplace safety and workers' compensation benefits. |
| F101-061-707 |
What Are Your Rights as a Worker? (English/Korean)
Fact sheet: Provides a brief overview of the worker rights administered by the Department of Labor and Industries. These include certain employment-related rights and rights pertaining to workplace safety and workers' compensation benefits. |
| F101-061-909 |
What Are Your Rights as a Worker? (English/Spanish)
Fact sheet: Provides a brief overview of the worker rights administered by the Department of Labor and Industries. These include certain employment-related rights and rights pertaining to workplace safety and workers' compensation benefits. |
| F101-063-000 |
A Guide to Hiring Independent Contractors in Washington State
Pamphlet/booklet: Designed to help employers determine if their workers are employees or independents under Washington's workers' compensation, workplace safety, wage and hour and unemployment tax laws. Includes a short "test" and helpful references. |
| F101-063-999 |
Guía para contratar Contratistas Independientes en el Estado de Washington
Pamphlet/booklet: Designed to help employers determine if their workers are employees or independents under Washington's workers' compensation, workplace safety, wage and hour and unemployment tax laws. Includes a short "test" and helpful references. |
| F101-068-000 |
2005 Annual Report - Department of Labor & Industries
Provides a statistical overview of results achieved in fiscal year 2005 (July 1, 2004, through June 30, 2005), budget information and a narrative introduction to the Department of Labor and Industries. |
| F101-077-303 |
If Family Members Work for You, Know Your Obligations (English/Thai)
Fact sheet: Provides an overview and resources to know your obligations when you have family members working for you. Relatives, including children, must be treated as employees with the same rights as any other paid worker in the state of Washington. |
| F101-077-404 |
If Family Members Work for You, Know Your Obligations (English/Russian)
Fact sheet: Provides an overview and resources to know your obligations when you have family members working for you. Relatives, including children, must be treated as employees with the same rights as any other paid worker in the state of Washington. |
| F101-077-505 |
If Family Members Work for You, Know Your Obligations (English/Vietnamese)
Fact sheet: Provides an overview and resources to know your obligations when you have family members working for you. Relatives, including children, must be treated as employees with the same rights as any other paid worker in the state of Washington. |
| F101-077-707 |
If Family Members Work for You, Know Your Obligations (English/Korean)
Fact sheet: Provides an overview and resources to know your obligations when you have family members working for you. Relatives, including children, must be treated as employees with the same rights as any other paid worker in the state of Washington. |
| F101-077-808 |
If Family Members Work for You, Know Your Obligations (English/Chinese)
Fact sheet: Provides an overview and resources to know your obligations when you have family members working for you. Relatives, including children, must be treated as employees with the same rights as any other paid worker in the state of Washington |
| F101-077-909 |
If Family Members Work for You, Know Your Obligations (English/Spanish) - Conozca sus obligaciones cuando miembros de su familia trabajan para usted
Fact sheet: Provides an overview and resources to know your obligations when you have family members working for you. Relatives, including children, must be treated as employees with the same rights as any other paid worker in the state of Washington. |
| F101-078-000 |
2006 Annual Report - Department of Labor & Industries
Provides a statistical overview of results achieved in fiscal year 2006 (July 1, 2005, through June 30, 2006), budget information and a narrative introduction to the Department of Labor & Industries. |
| F101-079-000 |
Applying for Your Washington Business License: A Step-by-Step Guide
Pamphlet: Concise, easy-to-read pamphlet that explains the steps to apply for a business license and what to do if you plan to employ workers. Includes how to apply to be a registered construction contractor. |
| F101-079-999 |
Applying for Your Washington Business License: A Step-by-Step Guide-Spanish (Aplicando para su Licencia de Negocio en Washington: Una guía detallada
Pamphlet: Concise, easy-to-read pamphlet that explains the steps to apply for a business license and what to do if you plan to employ workers. Includes how to apply to be a registered construction contractor. |
| F101-080-000 |
2007 Annual Report - Department of Labor & Industries
Provides a statistical overview of results achieved in fiscal year 2007 (July 1, 2006, through June 30, 2007), budget information and a narrative introduction to the Department of Labor & Industries. |
| F101-084-000 |
Directory of Web Resources for Washington Businesses
Pamphlet: Briefly describes Web pages that contain information of interest to Washington State businesses. Workers' compensation topics include "Quarterly reports--How do I file?" and "Claim-free Discount--Who gets it?" You also will find links to workplace safety rules, sample accident prevention programs, and information about safety grants, plus other information from L&I. Links to other state agency Web sites are included as well. |
| F101-086-000 |
2008 Annual Report for the Washington State Fund: Washington's State-run Workers' Compensation Program
Book: Introduces Washington State's Workers' Compensation Program, including rate-setting and investment policies, financial statement overview, and services available to help employers control workers' comp costs. |
| F101-087-000 |
Doing Business with the State of Washington: A Guide to Washington State Bid Opportunities
Pamphlet/booklet: Provides an overview of bid opportunities and processes for Washington State government with specific contact information for the Department of Labor & Industries. |
| F101-088-000 |
Small Business Liaison Info Card
Introduces L&I's Small Business Liaison and the services provided, along with information on subscribing to the e-newsletter, L&I News for Small Business. |
| F101-091-000 |
Plan for and Pay Your Taxes
Information card: Introduces Washington State's 28-minute DVD that covers state business taxes and workers' compensation premiums and provides information on how to file. |
| F101-091-034 |
Plan for and Pay Your Taxes DVD
DVD: Covers state business taxes and workers' compensation premiums and provides information on how to file. This 28-minute DVD can help employers plan ahead and obtain more information. |
| F120-097-000 |
L&I Facility Use Application and Agreement for Government Agencies
Use this form if you are a government agency wanting to use the L&I facility located at 7273 Linderson Way SW; Tumwater, WA. (4 pages) |
| F120-116-000 |
Application to Establish an Factory Assembled Structure Deposit Account with the Dept. of Labor and Industries
Use to establish a factory assembled structure (FAS) deposit account. FAS deposit accounts are for businesses or other entities that are not currently licensed or registered with L&I as electrical or construction contractors but are legally required to purchase work permits from L&I. (3 pgs) |
| F130-004-909 |
Protegiendo a los trabajadores de Washington (Protecting Washington Workers)
DVD: An innovative tool to teach Spanish-speaking workers about workplace rights while introducing English terminology. |
| F200-001-000 |
Getting Back to Work: It's Your Job and Your Future
Pamphlet/booklet: Briefly explains steps to return to work quickly and minimize the economic impact of time-loss. Also provides helpful resources. Intended for injured workers. |
| F200-001-999 |
Getting Back to Work: It's Your Job and Your Future-Spanish (Regresando a trabajar es su trabajo y su futuro)
Pamphlet/booklet: Briefly explains steps to return to work quickly and minimize the economic impact of time-loss. Also provides helpful resources. Intended for injured workers. |
| F200-002-000 |
Attending Doctor's Return-to-Work Desk Reference
Book: Discusses best practices in occupational medicine that help return an injured worker to his/her job as soon as medically possible. Identifies resources available from L&I and explains how to bill for return-to-work services. Three hours of Category 1 CME credit are offered for completing the test inside the handbook. |
| F200-003-000 |
Employer's Return-to-Work Guide
Pamphlet/booklet: Explains the benefits of 'return to work' from the employer's perspective, describes RTW options, and provides resource and contact information. |
| F200-005-000 |
2004 Year in Review
Pamphlet/booklet: Provides a financial summary of Washington State's workers' compensation system, July 1, 2003 through June 30, 2004. |
| F200-006-000 |
Help Fight Workers' Comp Fraud
Flier: Describes the New Hire Registry operated by the Department of Social and Health Services and how employers using it can help fight workers' compensation fraud. |
| F200-009-000 |
2005 Year in Review
Pamphlet: Provides a financial summary of Washington State's workers' compensation system, July 1, 2004, through June 30, 2005. Note: This publication was developed before the final data for the 2005 Industrial Insurance SAP Financial report were available. Equity Investments were presented at "cost" in the 2005 Year in Review and later correctly presented at "market" in the 2005 Industrial Insurance SAP Financial Information report. |
| F200-010-000 |
Reporting Injuries at Work, Employee Wallet Cards
Used by employers to teach their employees about the legal requirement to report accidents at work and who to notify if they have an accident at work. After completing the Employee Wallet Card form, the employer gives a wallet card to each employee. |
| F200-010-999 |
Reporting Injuries at Work, Employee Wallet Cards (Spanish)
Used by employers to teach their employees about the legal requirement to report accidents at work and who to notify if they have an accident at work. After completing the Employee Wallet Card form, the employer gives a wallet card to each employee. |
| F200-011-000 |
Claim & Account Center flier
Provides a brief overview of L&I's Claim & Account Center. This online application allows authorized users to check the status of a workplace injury claim and gives employers access to their account, including rates and classifications. |
| F200-012-000 |
2006 Year in Review
Pamphlet: Provides a financial summary of Washington State's workers' compensation system, July 1, 2005, through June 30, 2006. |
| F200-013-000 |
2007 Year in Review
Pamphlet: Provides a financial summary of Washington State's workers' compensation system, July 1, 2006, through June 30, 2007. This is the fourth Year in Review. In addition to the financial summary, it includes claim statistics and information about L&I's fraud prevention results. |
| F200-015-000 |
2008 Year in Review
Pamphlet: Provides a financial summary of Washington State's workers' compensation system, July 1, 2007, through June 30, 2008. This is the fifth Year in Review. In addition to the financial summary, the pamphlet highlights technology improvements for employers, including new features in the online Claim and Account Center. |
| F207-001-000 |
Application for Self-Insurance Certification
Used by employers to apply for self-insurance certification. |
| F207-005-000 |
Self-Insurance Report of Occupational Injury or Disease (SIF-5)
Used by only self-insured employers or their representatives to report initial time loss payments or to request interlocutory, wage, overpayment or closure orders. |
| F207-006-000 |
Quarterly Report for Self-Insured Business
Form used to submit Quarterly Report. If you need a copy of this form to complete your quarterly report, please contact Certification Services at (360) 902-6867. |
| F207-007-000 |
Annual Report of Self-Insured Business, 2008 (SIF-7)
Used by self-insured business for their 2008 Annual Report to L&I. This report must be received by L&I by March 1, 2009. Form is dated 1-09, instructions dated 12-08 are attached to the form. |
| F207-011-000 |
Quarterly Statement of Supplemental Benefits Paid for Self-Insured Employers
Used by self-insured employers to report their quarterly statement of supplemental benefits. |
| F207-011-111 |
Quarterly Statement of Supplemental Benefits Instructions
Instructions for filling out the quarterly statement of supplemental benefits. |
| F207-011-222 |
Social Security Offset Calculations Only Quarterly Statement of Supplemental Benefits Paid for Self-Insured Employers
Used by self-insured employers to request reimbursement from L&I for cost-of-living-adjustments paid to injured workers. |
| F207-020-111 |
Self-Insured Employers' Medical Only Claim Closure Order and Notice
Used by self-insured employers or their representatives, this is legal notification to an injured worker that their claim is being closed with medical benefits only. This order is used only when neither time loss compensation nor a permanent partial disability award has been paid. |
| F207-020-666 |
Self-Insured Employers' Medical Only Claim Closure Order and Notice - Cambodian
Used by self-insured employers or their representatives, this is legal notification to an injured worker that their claim is being closed with medical benefits only. This order is used only when neither time loss compensation nor a permanent partial disability award has been paid. |
| F207-020-777 |
Self-Insured Employers' Medical Only Claim Closure Order and Notice - Korean
Used by self-insured employers or their representatives, this is legal notification to an injured worker that their claim is being closed with medical benefits only. This order is used only when neither time loss compensation nor a permanent partial disability award has been paid. |
| F207-020-999 |
Notificación de Decisión de Cierre para reclamos Únicamente Médicos para Empleadores Autoasegurados
Used by self-insured employers or their representatives, this is legal notification to an injured worker that their claim is being closed with medical benefits only. This order is used only when neither time loss compensation nor a permanent partial disability award has been paid. |
| F207-037-909 |
Notice to Employees -- Self-Insurance (English/Spanish)
Required poster for self-insured businesses: Outlines what a worker employed by a self-insured business should do if a work-related injury or illness occurs. Note: Self-insured employers must display this poster where workers can see it. Get poster printing tips. |
| F207-039-000 |
Special Escrow Agreement
Used by self-insured employer as a means to provide surety. This is an agreement between the self-insurer and the bank to hold these securities in trust as collateral for its self-insured program. |
| F207-040-000 |
Agreement of Assumption and Guarantee of Workers' Compensation Liabilities - Application of Certification
Used by an employer to apply for self-insurance. |
| F207-040-001 |
Agreement of Assumption and Guarantee of Workers' Compensation Liabilities (Certified Self-Insurer)
Used by certified self-insured companies when they are acquired by another organization. New parent organization guarantees the self-insured workers' compensation liabilities of its new subsidiary. |
| F207-058-000 |
Assignment of Account Agreement
Used by a self-insured employer as an option to provide collateral for a total permanent disability claim. |
| F207-065-000 |
Self-Insurer's Pension Bond
Used by self-insured employers as an option to provide collateral for a permanent total disability claim. |
| F207-068-000 |
Self-Insurer's Bond - Existing Liabilities
Used to provide collateral for a self-insured program. |
| F207-070-000 |
Self-Insured Employers' Time Loss Claim Closure Order and Notice
Used by only self-insured employers or their representatives, this is legal notification to an injured worker that their claim is being closed. This order is used only when time loss compensation has been paid, but no permanent partial disability award is being paid. |
| F207-070-666 |
Self-Insured Employers' Time Loss Claim Closure Order and Notice -Cambodian
Used by only self-insured employers or their representatives, this is legal notification to an injured worker that their claim is being closed. This order is used only when time loss compensation has been paid, but no permanent partial disability award is being paid. |
| F207-070-777 |
Self-Insured Employers' Time Loss Claim Closure Order and Notice - Korean
Used by only self-insured employers or their representatives, this is legal notification to an injured worker that their claim is being closed. This order is used only when time loss compensation has been paid, but no permanent partial disability award is being paid. |
| F207-070-999 |
Notificación de Decisión de Cierre para reclamos de Tiempo Perdido para Empleadores Autoasegurados
Used by self-insured employers or their representatives, this is legal notification to an injured worker that their claim is being closed. This order is used only when time loss compensation has been paid, but no permanent partial disability award is being paid. |
| F207-079-000 |
Employers' Guide to Self-Insurance in Washington State
Book: Explains the process for employers to provide their own industrial insurance (workers’ compensation) coverage in Washington State. Also reviews surety requirements for self-insurance, reporting and recordkeeping requirements, claims processing, and compliance and legal issues. |
| F207-085-000 |
A Guide to Industrial Insurance Benefits for Employees of Self-insured Businesses
Pamphlet/booklet: Explains to employees of self-insured businesses their rights and responsibilities under industrial insurance law. Describes benefits and how to file a claim. |
| F207-085-999 |
A Guide to Industrial Insurance Benefits for Employees of Self-insured Businesses - Spanish (Guía de beneficios de seguro industrial para los empleados de empresas autoaseguradas)
Pamphlet/booklet: Explains to employees of self-insured businesses their rights and responsibilities under industrial insurance law. Describes benefits and how to file a claim. |
| F207-095-000 |
Self-Insured Employer Certificate of Excess Insurance
Used to provide excess insurance for a self-insurance program. |
| F207-110-000 |
Preparing for Your Self-Insurance Audit
Pamphlet/booklet: Helps self-insured employers understand and prepare for an audit. |
| F207-112-000 |
Irrevocable Stand By Letter of Credit
Used by a self-insurer to provide collateral for its program only if it has a net worth in excess of $500 million. |
| F207-112-111 |
Amendment of Irrevocable Standby Letter of Credit
Used by a self-insured employer to change items on the surety document such as amount of letter of credit issued as collateral. |
| F207-113-000 |
Memorandum of Understanding Irrevocable Standby Letter of Credit
This memorandum of understanding is between a self-insurer and L&I regading the use of an irrevocable standby letter of credit by the self-insurer as surety for its self-insurance obligations. |
| F207-120-000 |
Pension Bond Rider
Used by a self-insured employer to change items on the surety document such as amount of pension bond issued to secure a total permanent disability claim. |
| F207-125-000 |
Annual Supplemental Surety Information
Used by self-insured employers to assist in fulfilling surety requirements. |
| F207-129-000 |
Memorandum of Understanding
Used by a self-insured employer to signify the employer's obligation and responsibilities in conjunction with providing an annuity as collateral for a total permanent disability claim. |
| F207-134-000 |
Surety Rider
Used by a self-insured employer to amend or change items on the surety document such as the amount of a surety bond used as collateral. |
| F207-137-000 |
Special Escrow Account - Amendment Agreement
Used by a self-insured employer to amend or change items on the surety document such as the amount of the escrow agreement used as collateral. |
| F207-143-000 |
Acknowledgement of Security Interest
Used to acknowledge that funds have been deposited into an account at a bank for the purpose of providing payment for the workers' compensation benefits and assessments in the event of default by the self-insurer. |
| F207-155-000 |
Workers' Compensation Filing Information
Used by only self-insured employers to comply with WAC 296-15-400. The form provides information and instructions to employees of self-insured employers in case of an injury or development of an occupational disease. |
| F207-155-999 |
Cómo registrar un reclamo para la compensación del trabajador con empresas autoaseguradas
Used by only self-insured employers to comply with WAC 296-15-400. The form provides information and instructions to employees of self-insured employers in case of an injury or development of an occupational disease. |
| F207-156-000 |
SIF-5A Cover Sheet: Wage Calculations
Used by only self-insured employers and their representatives to calculate and report injured workers’ wages and time loss compensation rates. |
| F207-163-000 |
SIF-4 Self Insured Employer's Request for Denial of Claim
Used by self-insured employers or their representatives to notify an injured worker that the employer or representative is requesting that L&I deny their claim. |
| F207-164-000 |
Self-Insured Employers' Permanent Partial Disability Closure Order and Notice - PPD-TL
Used by self-insured employers or their representatives only, this is legal notification to an injured worker that their claim is being closed. This order is used only when time loss compensation has been paid, and a permanent partial disability award is also being paid. |
| F207-164-666 |
Self-Insured Employers' Permanent Partial Disability Closure Order and Notice - PPD-TL - Cambodian
Used by self-insured employers or their representatives only, this is legal notification to an injured worker that their claim is being closed. This order is used only when time loss compensation has been paid, and a permanent partial disability award is also being paid. |
| F207-164-777 |
Self-Insured Employers' Permanent Partial Disability Closure Order and Notice - PPD-TL -Korean
Used by self-insured employers or their representatives only, this is legal notification to an injured worker that their claim is being closed. This order is used only when time loss compensation has been paid, and a permanent partial disability award is also being paid. |
| F207-164-999 |
Notificación de Decisión de Cierre con Discapacidad Parcial Permanente para Empleadores Autoasegurados - PPD-TL
Used by self-insured employers or their representatives only, this is legal notification to an injured worker that their claim is being closed. This order is used only when time loss compensation has been paid, and a permanent partial disability award is also being paid. |
| F207-165-000 |
Self-Insured Employers' Permanent Partial Disability Closure Order and Notice - PPD-NTL
Used by self-insured employers or their representatives only, this is legal notification to an injured worker that their claim is being closed. This order is used only when time loss compensation has not been paid, but a permanent partial disability award is being paid. |
| F207-165-666 |
Self-Insured Employers' Permanent Partial Disability Closure Order and Notice - PPD-NTL -Cambodian
Used by self-insured employers or their representatives only, this is legal notification to an injured worker that their claim is being closed. This order is used only when time loss compensation has not been paid, but a permanent partial disability award is being paid. |
| F207-165-777 |
Self-Insured Employers' Permanent Partial Disability Closure Order and Notice - PPD-NTL - Korean
Used by self-insured employers or their representatives only, this is legal notification to an injured worker that their claim is being closed. This order is used only when time loss compensation has not been paid, but a permanent partial disability award is being paid. |
| F207-165-999 |
Notificación de Decisión de Cierre con Discapacidad Parcial Permanente para Empleadores Autoasegurados - PPD-NTL
Used by self-insured employers or their representatives only, this is legal notification to an injured worker that their claim is being closed. This order is used only when time loss compensation has not been paid, but a permanent partial disability award is being paid. |
| F207-171-000 |
Self-Insurance Vocational Services Closing Cover Sheet
Used by self-insured employers, their representatives, and vocational counselors to summarize the outcome of a vocational rehabilitation plan when submitting the closing report. |
| F207-176-000 |
Self-Insurance Certification Questionnaire
Used by employers applying to become self-insured to describe their proposed workers' compensation program. |
| F207-177-000 |
Application for Self-Insurance Claims Administrator Test
This form is used by experienced claims adjudicators for applying to take the Self-Insurance Claims Administrator Test. |
| F207-190-000 |
Self-Insurance Vocational Reporting Form
Used by self-insured employers and their representatives to report to L&I an injured worker's eligibility for vocational services or ability to work. This replaces F207-121-000 Employability Assessment Report (EAR). |
| F207-191-000 |
Self Insurance Continuing Education Report of Course Completion
Used by department-approved claims administrators to report course completion for obtaining continuing education credit. |
| F207-192-000 |
Self Insurance Continuing Education Sponsor/Instructor Application for Course Approval
Used by sponsors or instructors of continuing education courses, when requesting the department assign credit to a course so that department-approved claims administrators who attend can earn credit toward recertification under the Self Insurance Continuing Education program. |
| F207-193-000 |
Self-Insurance Electronic Data Reporting System (SIEDRS) Enrollment Form
Used by self-insured employers and third party administrators to enroll for participation in the Self Insurance Electronic Data Reporting System (SIEDRS). F207-197-000 is SIEDRS (Self-Insurance Electronic Data Reporting System) Data Change Request
|
| F207-194-000 |
Self-Insurance Electronic Data Reporting System (SIEDRS): Enrollment Package 2.0
Book: Explains the technical requirements for participating in SIEDRS, the Self-Insurance Electronic Data Reporting System |
| F207-195-000 |
Self Insurance Training Course Registration
Used by interested parties to register to attend continuing education courses provided by the L&I Self Insurance Section. |
| F207-197-000 |
SIEDRS (Self-Insurance Electronic Data Reporting System) Data Change Request
This is a data change request form. F207-193-000 is the Self-Insurance Electronic Data Reporting System (SIEDRS) Enrollment Form |
| F207-201-000 |
Help for Injured Workers of Self-Insured Businesses
Information card: Introduces the Office of the Ombudsman for Self-Insured Injured Workers. The ombudsman is appointed by the Governor to serve as an independent advocate for the rights of injured workers of self-insured employers. |
| F207-202-000 |
Your Independent Medical Exam: For Employees of Self-Insured Businesses
Pamphlet: Answers the most common questions about when and why an injured worker may be required to attend an independent medical exam. Includes the "IME Travel & Wage Reimbursement Request" form. This publication is for use only by self-insured businesses and their workers. |
| F207-202-999 |
Your Independent Medical Exam: For Employees of Self-Insured Businesses-Spanish (Su Examen Médico Independiente: Para empleadores de negocios autoasegurados)
Pamphlet: Answers the most common questions about when and why an injured worker may be required to attend an independent medical exam. Includes the "IME Travel & Wage Reimbursement Request" form. This publication is for use only by self-insured businesses and their workers. |
| F208-063-000 |
Medical Forms Request
Used to order L&I medical forms. |
| F211-141-000 |
Certificate of Coverage - SAMPLE ONLY
Sample of what the Certificate of Coverage looks like. You must order the forms you cannot download it off the internet. |
| F211-141-999 |
Certificado de Cobertura - Ejemplo
Sample of what the Certificate of Coverage looks like. You must order the forms you cannot download it off the internet.
|
| F212-034-000 |
Maritime Coverage
Used by the employer as a quick reference guide to explain which maritime jobs may or may not be covered by L&I. |
| F212-044-000 |
Coverage Agreement
An agreement between a worker and employer which states the worker's employment is principally localized in Washington state or another state. |
| F212-049-000 |
Guide for Payroll Service Providers Bulk Filing Worker's Compensation Quarterly Reports
Guide for Payroll Service Providers Bulk Filing Worker's Compensation Quarterly Reports |
| F212-050-000 |
Drywall Industry - Owner/Sub-Contractor Report
Used by drywall companies to file their quarterly report. Must accompany the Supplemental Quarterly Report for the Drywall Industry (F212-051-000). |
| F212-051-000 |
Supplemental Quarterly Report for the Drywall Industry
Used by drywall companies to file their quarterly report. Must accompany the Drywall Industry Owner/Sub-Contractor Report (F212-050-000). |
| F212-055-000 |
Worker's Compensaiton Employer's Quarterly Report for Industrial Insurance - SAMPLE ONLY
You must fill out this form quarterly even if you had no workers. These forms are mailed out quarterly to all employers. For instructions on how to complete the Quarterly Report, please refer to F212-239-000 which is available on the internet. |
| F212-196-000 |
Sports Teams Coverage Agreement
Used for a person who travels as part of their employment with a sports team and that their employment is principally localized in Washington state or another state. |
| F212-197-000 |
Workers' Compensation File Information Contract
This is an agreement between an individual and/or firm and L&I which authorizes access to L&I's computer database/application. (5 pages) |
| F212-222-000 |
Workers' Compensation Record Keeping and Reporting Guides
Packet: Contains eight quick reference cards covering topics related to workers' compensation record keeping and reporting. Topics include: computering worker hours, standard exception classifications, excluded employments and corporate officers. |
| F212-223-000 |
Mechanized Logging Supplemental Quarterly Report
Used by an employer to be submitted with the Employer's Quarterly Report for Industrial Insurance as a supplemental reporting form. |
| F212-224-000 |
Quarterly Reporting for Drywall
Used by drywall employers as a guide to completing quarterly and supplemental reports. This includes filled out samples of F212-050-000 and F212-051-000. |
| F212-224-999 |
Reporte Trimestral Para La Industria De Tabla De Yeso
Used by drywall employers as a guide to completing quarterly and supplemental reports. This includes filled out samples of F212-050-000 and F212-051-000. |
| F212-233-000 |
Washington Workers Insured Out-of-State: Employer’s Supplemental Quarterly Report for Workers’ Compensation
The purpose of 212-233-000 Supplemental reporting form is to allow employers to report out-of-state wages and hours as per the requirement in WAC 296-17-25203(8). |
| F212-234-000 |
Application for out of State Supplemental Reporting
The purpose of form 212-234-000 -Out of state applications- is to provide a means for an employer to formally request to receive the out-of-state supplemental report for a specific year and state. The form will also allow the department to convey out-of-state reporting requirements and to obtain information needed by the department to set a business up for supplemental reporting. |
| F212-235-000 |
Authorization for L&I to Accept and Process Quarterly Report from Accountant
Used by employers to give authorization to their accountants to submit quarterly reports in their behalf. |
| F212-239-000 |
Instructions for completing the Worker's Compensation Employer's Quarterly Report
Instructions for completing the Worker's Compensation Employer's Quarterly Report. A sample of the form F212-055-000 is also available on the internet. |
| F213-004-000 |
Cancellation of Elective Coverage - Sole Proprietors/Partner, Member of Limited Liability Company (LLC), Member of Limited Liability Partnership (LLP) or For-Profit Corporate Officers
Used by an employer to cancel workers' compensation coverage for Sole Proprietors/Partner, Member of Limited Liability Company (LLC), Member of Limited Liability Partnership (LLP) or For-Profit Corporate Officers. |
| F213-005-000 |
Cancellation of Elective Coverage for Excluded Employments
Used by employers to get the categories of employment that are not considered mandatory to have workers' compensation. If they had elected to have coverage this form is used to cancel previously elected coverage of workers' compensation. |
| F213-008-000 |
Construction Industry Classification Guide - Part 1 to Part 3
Book (loose-leaf manual): Helps contractors properly classify for industrial insurance purposes the work being performed by their employees on new wood-frame building construction projects.
Part 1 - Preface, Introduction, Overview, Record-keeping Requirements, Phases of Construction (Site Preparation, Foundation and Flatwork)
Part 2 - Phases of Construction (continued) -- Framing the Structure, Utility Construction, Enclosing the Structure, Interior Finish Work, Finishing the Site, Miscellaneous Operations
Part 3 - Appendixes
|
| F213-010-000 |
Contract: Report By Landowner - Forest, Range & Timber Industry
The landowner needs to complete and submit this form before any contractural agreement with a forest, range and/or timber industry contractor can start any work that is covered by this agreement. |
| F213-011-000 |
Contract: Report By Contractor - Forest, Range & Timber Industry
This report by the contractor needs to be completed and sent before any contractural agreement with a forest, range and/or timber industry landowner can start any work covered by this agreement.
|
| F213-013-000 |
Reforestation Contract Supplemental Report - Forest, Range and Timber Industry
Used by an employer to report worker hours for each individual contract with a timber landowner. This is a supplemental document to the Contract: Report by Contractor - Forest, Range & Timber Industry (F213-011-000). |
| F213-015-000 |
Reforestation Industry Continuation Sheet (Over $10,000)
Used by contractors to report contracts over $10,000. Reforestation industry contractors must report worker hours for each individual contract with a timber landowner. This form should accompany the quarterly report. |
| F213-019-000 |
Temporary Services Guide to Workers' Compensation Insurance
Used by L&I to assign industrial insurance classifications for workers of temporary help agencies. |
| F213-022-000 |
The ABCs of Classifications in Washington
Book: Aids in understanding Washington State's workers' compensation classification system and how classifications are applied to different types of businesses. |
| F213-023-000 |
Student Volunteers and Workers' Compensation Coverage
Fact sheet: Covers availability, limitations and cost of Washington State's optional workers' compensation coverage for student volunteers. |
| F213-042-000 |
Application for Elective Coverage - Sole Proprietor, Partners, For-Profit Corporate Officers, or Member/Managers of Limited Liability Company (LLC)
Used by employers to apply for workers' compensation coverage for non-mandatory employment. Shows a list of categories of employment that are not considered mandatory to have workers' compensation. |
| F213-112-000 |
Application for Elective Coverage of Excluded Employments
Used by employers to request coverage of workers' compensation for non-mandatory employment. Shows a list of employment categories to choose from that are not included within the mandatory coverage of workers' compensation. |
| F213-113-000 |
Application for Exclusion/Inclusion - Mandatory Coverage (Family Farm)
To exclude or include coverage for a family farm's children. |
| F214-010-000 |
Corporate Officers
Quick reference card: Explains the criteria to allow a corporate officer to be exempt from industrial insurance (workers' compensation) coverage. |
| F214-011-000 |
Record Keeping
Quick reference card: Identifies the type of records employers, including construction contractors, need to keep to allow L&I to compute premiums. |
| F214-012-000 |
Independent Contractors
Quick reference card: Provides information to help determine whether a "subcontractor" working for you meets the legal requirements to be an independent contractor, or whether he/she is actually a covered worker for workers' compensation (industrial insurance) purposes. |
| F214-013-000 |
Excluded and Exempt Employments
Quick reference card: Provides a list of employments excluded from workers' compensation coverage, including those eligible for optional coverage. |
| F214-014-000 |
Computing Worker Hours
Quick reference card: Shows employers how to figure workers' compensation premiums for different types of employees: hourly employees, salaried employees, commissioned personnel or employees paid for piecework |
| F214-016-000 |
Standard Exception Classification
Quick reference card: Provides basic information about standard exception classifications, which can be separately rated from the basic business classification for determining industrial insurance (workers' compensation) premiums. |
| F214-020-000 |
Audit Reference Card
Quick reference card: Answers questions employers may have about audits L&I conducts to verify the that workers' hours have been reported correctly and workers' compensation premiums have been calculated accurately. |
| F214-021-000 |
Limited Liability Companies (LLC)
Quick reference card: Reviews the requirements for members or managers of limited liability companies to be exempt from workers' compensation (industrial insurance) coverage. |
| F214-024-000 |
Drywall Contractors
Quick reference guide: Used by drywall contractors to get answers to questions about being a drywall contractor and how it relates to L&I. |
| F215-038-000 |
Request for Contract Release
This is the form used by public agencies to request L&I’s approval to release retainage. All known contractors are to be listed on the request form. This form is used for L&I purposes only. Public agencies submit a different form to DOR to obtain approval from DOR and ESD. There are two files - am image only Adobe file and a fillable word document. |
| F225-004-000 |
Your Workers' Compensation Rate Notice - SAMPLE ONLY
Form used to compute Your Workers' Compensation premiums. Page 2 has rate notice definitions. Sample only. |
| F241-021-000 |
Request for Manuals from Claims Training
Fillable form to purchase the "State Fund Claims Policy Manual" or the Workers' Compensation Adjudicator (WCA) and Claims Management (CM) Manual set. The costs must be added up manually, then the totals entered in the Total Cost column. |
| F242-052-000 |
Worker Verification Form
Completed by the injured worker if they are unable to work due to a workplace injury AND their employer is not paying their full wages. |
| F242-052-999 |
Formulario de Verificación de Empleo
Completed by the injured worker if they are unable to work due to a workplace injury AND their employer is not paying their full wages. |
| F242-055-000 |
Verification of School Enrollment
Used by the student and a school official each quarter to verify school enrollment. |
| F242-055-999 |
Verificiation of School Enrollment - Spanish VERIFICACIÓN DE
REGISTRO EN LA ESCUELA
Verificiation of School Enrollment - Spanish VERIFICACIÓN DE
REGISTRO EN LA ESCUELA |
| F242-056-000 |
Claim for Pension by Spouse or Children
Used by surviving spouse or children of a deceased worker to file a claim for benefits. |
| F242-056-999 |
Claim for Pension by Spouse or Children - Spanish Reclamo para Pensión de Esposo(a) o Los Niños
Used by surviving spouse or children of a deceased worker to file a claim for benefits. |
| F242-062-000 |
Claim for Pension By Dependents
Used by dependents of a deceased worker to file a claim for benefits. |
| F242-062-999 |
Reclamo for Pensión por Dependientes
Used by dependents of a deceased worker to file a claim for benefits. |
| F242-067-000 |
Inquiry for Assessment of Damages
Your answers to these questions will be used to assist in evaluating your damages if a claim is made against a liable third party. |
| F242-071-000 |
Occupational Disease & Employment History
Injured worker fills this out to document possible occupational disease and to show work history. |
| F242-071-111 |
Occupational Disease & Employment History (Cont)
Injuried worker fills out this document to show more work history. This form goes with Occupational Disease & Employment History (F242-071-000). |
| F242-071-911 |
Continuación del Historial de Trabajo Enfermedad Ocupacional
Injured worker fills this out to document possible occupational disease and to show work history. |
| F242-071-999 |
Historial de Trabajo (Enfermedad Ocupacional)
Injuried worker fills out this document to show more work history. This form goes with Occupational Disease & Employment History (F242-071-000). |
| F242-079-000 |
Application to Reopen Claim Due to Worsening Condition
Used by injured workers and doctors to apply to reopen an industrial injury or occupational disease claim that has been closed for longer than 60 days. |
| F242-079-999 |
Application to Reopen Claim due to Worsening Condition - Spanish APLICACIÓN PARA REABRIR UN RECLAMO
Spanish version. Used by injured workers and doctors to apply to reopen an industrial injury or occupational disease claim that has been closed for longer than 60 days. |
| F242-104-000 |
Workers' Guide to Industrial Insurance Benefits
Pamphlet/booklet: Explains a worker's rights and responsibilities under industrial insurance law. Describes benefits and how to file a claim. |
| F242-104-111 |
Workers' Guide to Industrial Insurance - Russian
Pamphlet/booklet: Explains a worker's rights and responsibilities under industrial insurance law. Describes benefits and how to file a claim. |
| F242-104-222 |
Workers' Guide to Industrial Insurance - Vietnamese
Pamphlet/booklet: Explains a worker's rights and responsibilities under industrial insurance law. Describes benefits and how to file a claim. |
| F242-104-999 |
Workers' Guide to Industrial Insurance Benefits - Spanish (Guía de los trabajadores para beneficios del seguro industrial)
Pamphlet/booklet: Explains a worker's rights and responsibilities under industrial insurance law. Describes benefits and how to file a claim. |
| F242-107-000 |
Address Change Request
Used by the pensioner to notify L&I of a new mailing address. L&I must receive this form by the first day of the month so your monthly payment is received in a timely manner. |
| F242-107-999 |
Solicitud de Cambio de Domicilio
Used by the pensioner to notify L&I of a new mailing address. L&I must receive this form by the first day of the month so your monthly payment is received in a timely manner. |
| F242-109-000 |
Employment History Form
Used by Injured Worker to report their employment history for the past three years, and the detailed wages for each job. |
| F242-109-999 |
Historial de Empleo
Used by injured worker to report their employment history for the past three years and the wages at each job.
|
| F242-130-000 |
Report of Industrial Injury or Occupational Disease (Accident Report ) (ROA)
Used by injured workers, doctors, and employers to report an industrial injury or occupational disease. This report is not available online. Order by the number of copies you need. Do not order by box or case. If you are an injured worker, ask your doctor for a copy of this form. |
| F242-130-999 |
Informe de Lesion o Enfermedad Ocupacional - Hoja de Referencia
Used by Spanish-speaking injured worker who is filing a workers' compensation claim for an industrial injury or occupational disease. This form provides instructions in Spanish for completing the F242-130-000 Report of Industrial Injury or Occupational Disease. Available in L&I warehouse August 1. |
| F242-173-111 |
Declaration of Entitlement for Widow or Widower Benefits Under Industrial Insurance
Used by the widow/widower whose spouse died of a work related injury or accident. This form must be completed, signed, notarized and returned to L&I within 30 days for non interruption of your benefits. |
| F242-173-222 |
Declaration of Entitlement for Guardian Benefits under Industrial Insurance
Used by a guardian or other person having custody of the minor or disabled children or dependents of a deceased worker to declare their entitlement to receive the pension benefits for those children/dependents in their care and custody. |
| F242-173-333 |
Declaration of Entitlement for Dependent of Deceased Worker Benefits Under Industrial Insurance
Used by a dependent of a worker whose death was related to an on the job injury or accident. This form must be completed, signed, notarized and returned to L&I within 30 days for non interruption of benefits. |
| F242-173-444 |
Declaration of Entitlement for Totally Disabled Worker Benefits Under Industrial Insurance
Used by a totally permanently disabled worker. This form must be completed, signed, notarized and returned to L&I within 30 days for non interruption of benefits. |
| F242-173-911 |
Declaración De Derechos Para Viuda(O) Bajo El Programa De Compensación Y Beneficios Para Trabajadores
Used by the widow/widower whose spouse died of a work related injury or accident. This form must be completed, signed, notarized and returned to L&I within 30 days for non interruption of your benefits. |
| F242-173-922 |
Declaración De Derechos Para Padres O Tutor Bajo El Programa De Compensación Y Beneficios Para Trabajadores
Used by a guardian or other person having custody of the minor or disabled children or dependents of a deceased worker to declare their entitlement to receive the pension benefits for those children/dependents in their care and custody. |
| F242-173-933 |
Declaración De Derechos Para Dependiente Del Trabajador Fallecido Bajo El Programa De Compensación Y Beneficios Para Trabajadores
Used by a dependent of a worker whose death was related to an on the job injury or accident. This form must be completed, signed, notarized and returned to L&I within 30 days for non interruption of benefits. |
| F242-173-944 |
Declaración De Derechos Para Trabajador Totalmente Discapacitado Bajo El Programa De Compensación Y Beneficios Para Trabajadores
Used by a totally permanently disabled worker. This form must be completed, signed, notarized and returned to L&I within 30 days for non interruption of benefits. |
| F242-174-000 |
Authorization for Deposit of Payments
Used by pensioner to authorize L&I to deposit the pension payment to any designated financial institution. |
| F242-174-909 |
Authorization for Deposit of Payments - English/Spanish AUTORIZACIÓN PARA
DEPÓSITOS DE PAGOS
Used by pensioner to authorize L&I to deposit the pension payment to any designated financial institution. NOTE: F242-177-999 is the Direct Deposit Letter in Spanish |
| F242-177-000 |
Direct Deposit Letter
Used by the pensioner to learn about direct deposit. It accompanies the Authorization for Deposit of Payments (F242-174-000) form. |
| F242-177-999 |
Depósito Directo
Used by the pensioner to learn about direct deposit. It accompanies the Authorization for Deposit of Payments- Spanish (F242-174-909) form. |
| F242-191-909 |
Notice to Employees -- If a Job Injury Occurs (English/Spanish)
Required poster: Outlines the steps a worker should take if a job-related injury or illness occurs. Also briefly describes the benefits available through Washington's workers' compensation system. Note: 'Employers who receive industrial insurance coverage from L&I must display this poster where workers can see it. English and Spanish online versions will print separately. Get poster printing tips. |
| F242-243-000 |
Notice of Occupational Disease or Infection
Used by medical providers to notify L&I that an occupational disease or infection has been diagnosed and that the worker has been advised that their condition may be work-related. This form can be used if the worker does not complete a Report of Accident or Occupational Disease (ROA) but should not be completed in place of an ROA. |
| F242-352-000 |
Pension Benefits for Washington's Workers' Compensation Program
Pamphlet/booklet: Answers the most common questions about pension benefits under Washington’s workers’ compensation system. |
| F242-352-999 |
Pension Benefits for Washington's Workers' Compensation Program - Spanish (Beneficios de Pensión para el Programa de Compensación para Trabajadores de Washington)
Pamphlet/booklet: Answers the most common questions about pension benefits under Washington’s workers’ compensation system. |
| F242-363-909 |
How to Protest a Department of Labor and Industries Decision (English/Spanish)
Fact sheet: Explains how an injured worker can protest decisions on his/her claim and gives deadlines for taking action. |
| F242-382-000 |
Letter of Intent for School Enrollment
Use by a full-time student who is entitled to receive pension benefits. The student must be at least 18 years old and no older than 23 years old. This form is to prove the students intention to register in an accredited school during the next quarter/semester. |
| F242-382-999 |
Letter of Intent for School Enrollment - Spanish CARTA DE INTENCIÓN DE
REGISTRO EN UNA ESCUELA
Letter of Intent for School Enrollment - Spanish CARTA DE INTENCIÓN DE
REGISTRO EN UNA ESCUELA |
| F242-385-000 |
Insurer Activity Prescription Form
This form is used by health-care providers to communicate an injured worker's status, physical capacities, verification of inability to work (time-loss) and treatment plans. Employers and attorneys may not print or order these forms nor ask doctors to complete them. To print an APF, click on the title of the form in the box above. For more information about the form see the APF website at: www.ActivityRX.Lni.wa.gov |
| F242-387-000 |
Independent Medical Exam Doctor's Estimate of Physical Capabilities
IME Doctor’s Estimate of Physical Capacities: For use by independent examiners when asked to estimate physical capacities as part of an IME requested by the department. |
| F242-388-000 |
State Fund Claims Address Change Request
Completed and signed by a State Fund injured worker to notify L&I of a change in address. All address changes must be submitted in writing and signed by the injured worker. |
| F242-388-999 |
State Fund Claims Address Change Request - Spanish (Solicitud de Cambio de Domicilio para Reclamos del Fonda Estatal)
Completed and signed by a State Fund injured worker to notify L&I of a change in address. All address changes must be submitted in writing and signed by the injured worker. |
| F242-391-000 |
Application for Pension Benefits by Spouse or Children
Used by a spouse or children to apply for pension survivor benefits if a total permanent disabled worker dies. |
| F242-391-999 |
Application for Pension Benefits by Spouse or Children - Spanish Aplicación para beneficios de pensión presentado por el cónyuge o hijos
Used by a spouse or children to apply for pension survivor benefits if a total permanent disabled worker dies. |
| F242-393-000 |
Pension Benefits Questionnaire
Used by an injured worker who receives an order that states he or she is totally permanently disabled. This questionnaire must be completed in full and all necessary documents attached before his or her pension benefit options can be calculated. |
| F242-393-999 |
Pension Benefits Questionnaire - Spanish CUESTIONARIO PARA BENEFICIOS DE PENSIÓN
Used by an injured worker who receives an order that states he or she is totally permanently disabled. This questionnaire must be completed in full and all necessary documents attached before his or her pension benefit options can be calculated. |
| F242-395-000 |
Affidavit for Time Loss Compensation Benefits
Completed by injured workers contending eligibility for payment of back time loss benefits for a period that exceeds six months or $25,000. Injured workers requesting benefits for current time missed from work due to a work-related injury should use the F242-052-000 Worker Verification Form. |
| F242-395-999 |
F242-395-999 Affidavit_for_Time_Loss_Compensation_Benefits spanish DECLARACIÓN FIRMADA PARA COMPENSACIÓN DE TIEMPO PERDIDO
F242-395-999 Affidavit_for_Time_Loss_Compensation_Benefits spanish DECLARACIÓN FIRMADA PARA COMPENSACIÓN DE TIEMPO PERDIDO Completed by injured workers contending eligibility for payment of back time loss benefits for a period that exceeds six months or $25,000. Injured workers requesting benefits for current time missed from work due to a work-related injury should use the F242-052-999 Worker Verification Form. |
| F245-010-000 |
Statement for Compound Prescription
To have L&I reimburse an injured worker for costs associated with purchasing their compound prescriptions less any co-payment. This form is filled out by the pharmacist. These forms will be accepted by L&I. They may not be accepted by all Medical Bill Processors due to lack of a barcode. |
| F245-023-000 |
Performance Based Physical Capacities Evaluation
Used by occupational and physical therapy providers as an optional reporting format for a Performance-based Physical Capacities Evaluation. |
| F245-030-000 |
Statement for Retraining and Job Modification Services
Used by the injured worker for reimbursment of expenses for retraining related to their worker's compensation claim. This form is signed by the injured worker and the provider. |
| F245-037-000 |
Case Transfer Card
Used by injured worker to notify claim manager and request authorization to transfer care to a different doctor. |
| F245-037-999 |
Case Transfer Card (Spanish) Tarjeta para transferencia de caso
Used by injured worker to notify claim manager and request authorization to transfer care to a different doctor. |
| F245-043-000 |
REFUND NOTIFICATION Refunding Money to L&I to correct your account?
Used to Refund Money to L&I to correct your account REFUND NOTIFICATION |
| F245-046-000 |
Provider Account Application - Independent Medical Examiner (IME)
In order to do independent medical exams a provider must obtain a provider account number with L&I. This packet includes the application and agreement with instructions, IME Provider Exam sites form (F245-047-000) and Request for Taxpayer ID and Certification - Form W-9 (F248-036-000) (8 pages). |
| F245-047-000 |
Independent Medical Examination (IME) Provider Exam Sites
List the locations where the doctor does independent medical exams on a regular basis. |
| F245-049-000 |
Hearing Services Worker Information
This is a list of the rights and conditions when an injured worker applies for hearing aids. |
| F245-050-000 |
Termination of Agreement (Rescission)
To be filled out by the injured worker who wants to return hearing aids. |
| F245-051-000 |
Approved Independent Medical Examiner (IME) Update
To update or correct the IME's contact, availability, qualificaitons and/or exam sites. |
| F245-052-000 |
Resource Utilization Group (Rug) Residential Care Services for L&I injured Workers
Filled out by the provider when they treat an injured worker. See web links below for: Latest payment amounts, Updates and corrections, and Review payment policy. |
| F245-053-000 |
Independent Medical Exam Comments
Used by the injured worker to provide comments to L&I about their recent medical exam by an IME. |
| F245-053-999 |
Comentarios Sobre el Exámen Médico Independente
Used by the injured worker to provide comments to L&I about their recent medical exam by an IME.
|
| F245-055-000 |
Submission of Provider Credentials for Interpretive Services
Used to apply as a interpretive service provider and to show what language(s) you hold credentials for.
F248-011-000 Provider Application and Notice is added to this form. |
| F245-056-000 |
Interpretive Services Appointment Record
Used when an interpreter is appointed to interpret for an injured worker during their medical visits. |
| F245-057-000 |
Frequently Asked Questions about Job Modifications
Fact sheet: Answers questions employers, workers and doctors may have about job modifications, including when to request a job-modification consultant and who pays for the costs involved. |
| F245-058-000 |
Independent Medical Exam Template
Template used by a doctor during an independent medical exam. |
| F245-059-000 |
Physical Therapy / Occupational Therapy Progress Report to Claim Managers
The physical / occupational therapist uses this report to identify the clinical goals and return to work objectives of the injured worker. |
| F245-072-000 |
Statement for Miscellaneous Services
Used for miscellaneous services of an injured worker. Such as: dental, glasses, medical equipment, transportation, home services, retraining, etc. These forms will be accepted by L&I. They may not be accepted by all Medical Bill Processors due to lack of a barcode. |
| F245-072-999 |
Instructions in Spanish for completing the form F245-072-000 Statement for Miscellaneous Services
Instructions in Spanish for completing the form F245-072-000 Statement for Miscellaneous Services |
| F245-094-034 |
L&I Toolkit for Providers and Billing
CD: Includes informational materials for new providers. Also contains the rules and policies for reimbursing medical services and lists maximum fees. This CD was previously titled Medical Aid Rules and Fee Schedules. To access the fee schedules, see the "Fee Schedules" Web page listed on the full description page for this publication. |
| F245-100-000 |
Statement for Pharmacy Services
To have L&I reimburse an injured worker for costs associated with purchasing their prescriptions less any co-payment. This form is filled out by the pharmacist. These forms will be accepted by L&I. They may not be accepted by all Medical Bill Processors due to lack of a barcode. |
| F245-127-000 |
CMS 1500 (formerly L&I Health Insurance Claim form)
Used by providers to be reimbursed for services. It is NOT for use by injured workers to submit a claim to L&I. |
| F245-145-000 |
Travel Reimbursement Request
Injured workers use this form to request reimbursement for travel expenses used to receive treatment, retraining and/or vocational services. These forms will be accepted by L&I. They may not be accepted by all Medical Bill Processors due to lack of a barcode. |
| F245-145-999 |
Travel Reimbursement Request Spanish (Solicitud para el reembolso de gastos de viaje)
Injured workers use this form to request reimbursement for travel expenses used to receive treatment, retraining and/or vocational services. |
| F245-183-000 |
Providers Request for Adjustment
Providers use this to report total overpayment, partial overpayment and/or underpayment by L&I. These forms will be accepted by L&I. They may not be accepted by all Medical Bill Processors due to lack of a barcode. |
| F245-224-000 |
Your Independent Medical Exam
Pamphlet/booklet: Answers the most common questions about independent medical exams and when and why an injured worker may be required to receive one. Includes the "IME Travel & Wage Reimbursement Request" form. |
| F245-224-999 |
Your Independent Medical Exam - Spanish (Su Exámen Médico Independiente)
Pamphlet/booklet: Answers the most common questions about independent medical exams and when and why an injured worker may be required to receive one. Includes the "IME Travel & Wage Reimbursement Request" form. |
| F245-299-000 |
Consultation Referral
The attending doctor refers an injured worker for consultation for clinical issues, 120 day consultation and/or closing, etc. |
| F245-340-000 |
Labor and Industries Prosthetic Device Request Form
Labor and Industries Prosthetic Device Request Form |
| F245-346-000 |
Job Modification Assistance Application
For use by an vocational counselor, employer, etc. to request modification for the injured workers job. This may involve tools and equipment that is purchased through L&I. |
| F245-350-000 |
Pre-Job Accommodation Assistance Application
For use by a therapist or vocational provider to request job modification for an injured worker before the injured workers is employed, possibly in a retraining program. This may involve tools and equipment that is purchased through L&I.
|
| F245-351-000 |
Vocational Training Plan Ownership Agreement for Tools and Equipment
Injured worker agrees to the ownership terms of the tools and/or equipment purchased as part of their training plan by L&I. |
| F245-353-000 |
1st 52 Week Period Plan Time Encumbrance
To record the work plan time for the first 52 weeks. For use only with plans approved before 1/1/2008. For plans approved after 1/1/2008, use F245-376-000. |
| F245-354-000 |
1st 52 Week Period Training Plan Cost Encumbrance
To record the training plan costs for the first 52 weeks. For use only with plans approved before 1/1/2008. For plans approved after 1/1/2008, use F245-374-000.
|
| F245-355-000 |
1st 52 Week Period Board & Room Cost Encumbrance
To record the costs for room and board for the first 52 weeks. For use only with plans approved before 1/1/2008. For plans approved after 1/1/2008, use F245-372-000. |
| F245-356-000 |
2nd 52 Week Period Plan Time Encumbrance
To record the work plan time for the second 52 weeks. For use only with plans approved before 1/1/2008. For plans approved after 1/1/2008, use F245-376-000. |
| F245-357-000 |
2nd 52 Week Period Training Plan Cost Encumbrance
To record the training plan costs for the second 52 weeks. For use only with plans approved before 1/1/2008. For plans approved after 1/1/2008, use F245-374-000.
|
| F245-358-000 |
2nd 52 Week Period Board & Room Cost Encumbrance
To record the costs for room and board for the second 52 weeks. For use only with plans approved before 1/1/2008. For plans approved after 1/1/2008, use F245-372-000.
|
| F245-359-000 |
Opioid Progress Report Supplement: Chronic, Noncancer Pain
When prescribing opioids for chronic, noncancer pain; the attending physician must submit this form, or an equivalent form at least every 60 days. Providers are encouraged to submit after each visit. |
| F245-360-000 |
1st 52 Week Period Transportation Cost Encumbrance
Transportation costs for the first 52 weeks. For use only with plans approved before 1/1/2008. For plans approved after 1/1/2008, use F245-375-000. |
| F245-361-000 |
2nd 52 Week Period Transportation Cost Encumbrance
Transportation costs for the first 52 weeks. For use only with plans approved before 1/1/2008. For plans approved after 1/1/2008, use F245-375-000.
|
| F245-365-000 |
Provider Accounts Change Form
Providers use this form to notify L&I of a change of their business address, billing address and account termination. Also has info on how to notify L&I on a tax ID (EIN) number change, tax ID address change and/or name change. |
| F245-367-000 |
UB04 HCFA 1450
Used by hospitals to bill L&I for inpatient/outpatient services. This version includes NPI number. |
| F245-369-000 |
It's Good Business to Do Business with L&I
Pamphlet: Explains the importance of quality health care in the treatment of injured workers. Describes the services L&I offers health-care providers who treat injured workers, including provider account representatives who can answer questions and assist with complex billing issues. |
| F245-372-000 |
Housing and Board Cost Encumbrance
To record the costs for housing and board. For use only with plans approved after 1/1/2008. For plans approved before 1/1/2008, use form F245-355-000 or F245-358-000. |
| F245-374-000 |
Training Plan Cost Encumbrance
To record the training costs. For use only with plans approved after 1/1/2008. For plans approved before 1/1/2008, use form F245-354-000 or F245-357-000. |
| F245-375-000 |
Transportation Cost Encumbrance
To record the costs for transportation. For use only with plans approved after 1/1/2008. For plans approved before 1/1/2008, use form F245-360-000 or F245-361-000. |
| F245-376-000 |
Plan Time Encumbrance
To record the work plan time. For use only with plans approved after 1/1/2008. For plans approved before 1/1/2008, use form F245-353-000 or F245-356-000. |
| F245-377-000 |
Long Term Care Assessment Tool
You must mail or fax form. No emailed forms are accepted. This assessment tool is provided by L&I assessment to determine the medically appropriate level of care that will meet the Injured Worker’s needs, abilities and safety in a residential facility. This assessment is not intended as a substitute for DSHS annual assessment & treatment plan, which is the sole financial responsibility of the facility. |
| F245-379-000 |
Provider Account Application Supplement & Notice for Orthopedic & Neurological Surgeon Quality Pilot
Used by providers (Orthopedic, Neurological and Hand Surgeons) to participate in the Orthopedic and Neurological Surgeon Quality Pilot. |
| F245-380-000 |
Provider Account Application Supplement And Notice for PA-C and ARNP Orthopedic & Neurological Surgeon Quality Pilot
Used by providers (PA-Cs, and ARNPs that work at a participating clinic) to participate in the Orthopedic and Neurological Surgeon Quality Pilot. |
| F245-381-000 |
Application for Self-Insurance Certification Supplement for the Orthopedic & Neurological Surgeon Quality Pilot
Used by self-insured employers to participate in the Orthopedic & Neurological Surgeon Quality Pilot |
| F245-382-000 |
Notice of Independent Medical Exam No-Show or Late Cancellation
Notice of Independent Medical Exam No-Show or Late Cancellation |
| F245-383-000 |
Independent Medical Examination Fax Cover Sheet
Independent Medical Examination Fax Cover Sheet |
| F245-384-000 |
Hearing Aid Purchase and Repair Authorization Requests
Hearing Aid Purchase and Repair Authorization Requests |
| F247-003-000 |
Department of Labor and Industries Home Modification Acknowledgement of Responsibilities
Used by both workers and bidding contractors to read, sign and submit to L&I to verify that they have read, understand and accept their respective responsibilities in the home modification process. |
| F248-011-000 |
Provider Account Application
For providers to apply for a provider account number with L&I. Includes the Form W-9 Request for Taxpayer ID Number and Certification (F248-036-000). 10-2009 version is internet only, not printed. |
| F248-025-000 |
Mailing Addresses and Telephone Numbers
This form has a list of mailing addresses and document types a provider uses to send to L&I. There is also a list of phone numbers. |
| F248-031-000 |
Electronic Billing Authorization
To authorize L&I to accept electronically submitted bills for services provided to injured workers (3 pages). |
| F248-036-000 |
Request for Taxpayer ID - Form W-9 Provider Accounts
Use this form to obtain your taxpayer ID number. |
| F248-040-000 |
Hotline Tips for Medical Services Providers
Fact sheet: Provides tips to help medical service providers quickly obtain answers to claims and billing questions. Introduces L&I's Provider Hotline, Interactive Voice Response Message System and online Claim & Account Center. |
| F248-055-000 |
Occupational or Physical Therapy Treatment Authorization Fax Request
Used by a therapy provider/clinic to request authorization for outpatient occupational or physical therapy services for L&I claims. |
| F248-100-000 |
General Provider Billing Manual
Used by providers to bill L&I for reimbursement. |
| F248-160-000 |
Statement for Home Nursing Services
Used to bill L&I for reimbursement of home nursing services. |
| F248-343-000 |
Payroll Service Provider - Quarterly Reporting Bulk Filing Enrollment Form
Used by payroll services to enroll and register with L&I for downloading/uploading account information from the Express Filing site using an electronic list (text file) of accounts. |
| F248-355-000 |
Power of Attorney for Electronic Remittance Advice
Providers complete this form to authorize a clearinghouse or third party to receive the EDI 835 Electronic Remittance Advice file from L&I's Provider Express Billing (PEB). |
| F248-357-000 |
Massage Practitioner (LMP) Treatment Authorization FAX Request
Used by a licensed massage practitioner/clinic to request authorization for outpatient massage therapy services for L&I claims. |
| F248-361-909 |
Provider Application and Notice for Spanish Speaking Providers Outside the United States- English/Spanish
This form is to be used by Spanish speaking Medical Providers out side the United States. . This form now includes both English and Spanish versions of the Provider form and letters. File includes W8ECI form from IRS and instructions for the form. Both IRS form and instructions are in English.This version is not the same as the English version, which is intended for use by Providers in the United States |
| F249-006-111 |
Third Party Recovery Worksheet
Used by third party attorneys to calculate distribution of proposed settlements in third party claims. |
| F249-008-000 |
Third Party Action - State Fund
Pamphlet/booklet: Summarizes the legal rights and options an injured worker has if a third-party action pertains to his/her workers' compensation claim. Includes the form that must be completed by the worker. Note: The form can be filled in using Adobe Reader, but must be printed, signed and mailed. |
| F249-008-999 |
Injured by a Third Party? You Have Legal Options - Spanish (¿Lesionado por
un tercero? Usted tiene opciones legales)
Pamphlet/booklet: Summarizes what action to take when a workplace injury is caused by a defective product or defective machine or by a person who is not a co-worker. |
| F249-017-000 |
Application for Inclustion on List of Eligible Attorneys
Used by attorneys to be included on the Workers' Compensation Special Assistant Attorney General Program eligible list for Third Party claims. |
| F249-021-000 |
Supplemental Agreement Third Party Pharmacy Provider
This agreement is to define access, performance and legal requirements for third party pharmacy billers who submit bills to and receive payment from L&I on behalf of pharmacy providers. This agreement authorizes L&I to accept and remit monies due the Pharmacy using a third party pharmacy biller. |
| F250-003-000 |
Individual Retrospective Rating Plan Agreement
Used by employers to set up an agreement between them and L&I authorizing their participation in retrospective rating. |
| F250-004-000 |
Group Retrospective Rating Agreement
Used by organizations to set up an agreement with L&I authorizing their participation in retrospective rating. |
| F250-006-000 |
Retrospective Rating
Pamphlet: Provides information about how employers can enroll in a Retrospective Rating program to lower claim costs and reduce workers' compensation experience factor. |
| F250-007-000 |
Application for Group - Retrospective Rating
Used by organizations that want to form a retrospective rating group, or by established groups to modify their retro plan or maximum premium ratio. |
| F250-016-000 |
Application for Group Membership & Authorization for Release of Insurance Data
Used by employers who want to join a retrospective rating group; also, to authorize Labor & Industries to release the employers' insurance data to the retrospective rating group they want to join. |
| F252-001-000 |
Medical Examiners' Handbook
Book: A publication for independent medical examiners, attending doctors and consultants, this document contains guidelines, sample reports and billing procedures for preparing and conducting impairment ratings and IMEs in Washington's workers' compensation system. The publication also includes a feature to assist physicians in attaining three hours of Category 1 CME credit by completing the self-assessment test at the end of the handbook. See also Self-Assessment Exam at www.Lni.wa.gov/IPUB/252-001-000Exam.pdf. L&I and the authors have no financial interest or other relationship with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this document. |
| F252-004-000 |
Attending Doctor's Handbook
Book: This handbook contains useful information to help providers who treat patients in the workers' compensation system. The publication also includes a feature to assist physicians in attaining three hours of Category 1 CME credit by completing the exam at the end of the handbook. L&I and the authors have no financial interest or other relationship with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this document. |
| F252-005-000 |
Chiropractic Physician's Guide
Book: Describes the responsibilities of the attending chiropractic physician in preventing claims problems. |
| F252-006-000 |
Doctor's Worksheet for Rating Dorso-Lumbar & Lumbo-Sacral Impairment
This worksheet is to help the attending physician perform impairment rating on their patients with permanent partial disability of the Dorso-Lumbar or Lumbo-Sacral spine. |
| F252-007-000 |
Hearing Impairment Calculation Worksheet
Used by the attending doctor to determine hearing loss. |
| F252-010-000 |
Medical Treatment Guidelines
This is an outdated book of medical treatment guidelines and is available for archival reference only. The current medical treatment guidelines can be found at http://www.lni.wa.gov/ClaimsIns/Providers/Treatment/TreatGuide/default.asp where each guideline has its own link and file.
|
| F252-013-000 |
Medical Device Review Request
This form is so L&I's Office of the Medical Director can evaluate medical device(s) that the attending physican wants to use to treat an injured worker. |
| F252-017-000 |
Vocational Providers Application and Notice
Used to obtain a vocational provider account number with L&I. This form includes a copy of F248-036-000 "Request for Taxpayer ID number and Certification". (12 pages) |
| F252-021-000 |
Individual Vocational Provider Account Change Form
To change an individual's (service provider's) name, add or delete referral categories, update certifications, leaving a firm, intern supervisor changes, and/or adding or deleting a branch for referrals. |
| F252-022-000 |
Firm Vocational Provider Account Change
To change a firm's (payee provider's) branch address within the same service location, contact info, tax info, adding or deleting designee for your firm. |
| F252-027-000 |
Vocational Closing Report Routing Sheet
Routing slip that accompanies the Vocational Services Closing Cover Sheet (F252-028-000) which is used to close vocational services to an injured worker. |
| F252-028-000 |
Vocational Services Closing Cover Sheet
Used to close vocational services of an injured worker. This form is attached to Vocational Closing Report Routing Sheets F280-013-000, F280-014-000 or F252-027-000. |
| F252-029-000 |
Assessment Closing Report
Used by only private sector vocational rehabilitation providers to document vocational assessment to determine if a worker is employable based upon transferable skills or needs further vocational services such as retraining. |
| F252-032-000 |
Sample Self-Employment Agreement
Sample of a letter a return to work person would use to assist L&I in determining whether services or funds should be authorized to assist them in becoming self-employed.
|
| F252-033-000 |
Sample on-the-job Training Agreement
Sample on-the-job Training Agreement |
| F252-035-000 |
Sample Job Offer Letter
Sample of a job offer letter from a business to an injured employee. |
| F252-040-000 |
Employer's Job Description
Used by employer of record to prepare a written job description for a light duty job, modified duty job, or alternative job when an injured worker is unable to work due to an industrial injury or occupational disease. The form includes a description of the job tasks, machinery, tools, equipment and personal protective equipment used, and the physical demands of the job. After completing the employer's job description form, the employer gives it to the injured worker's doctor for review and approval. |
| F252-051-000 |
Sample Format for Vocational Testing Report
Used by vocational counselors to test an injuried worker's skills and abilities. |
| F252-052-000 |
Sample Format for Vocational Evaluation Testing Plan
Used by vocational counselors to evaluate the testing plan of the injuried worker.
|
| F252-056-000 |
Doctor's Worksheet for Rating Cervical and Cervico-Dorsal Impairment
Doctor's Worksheet for Rating Cervical and Cervico-Dorsal Impairment |
| F252-060-000 |
Home Modification for Workers with Catastrophic Injuries
Fact sheet: Answers questions about the home modification benefit in Washington State's workers' compensation program, who qualifies, what L&I can pay, and where to get more information. |
| F252-061-000 |
Home Modification for Workers with Catastrophic Injuries - Questions and Answers for Contractors
Fact sheet: Answers questions about the home modification benefit in Washington State's workers' compensation program and the bid process for contractors interested in this work. |
| F252-070-000 |
Sample Physical Demands Job Analysis
Used by vocational rehabilitation counselors (VRCs) to document the physical demands of jobs. |
| F262-009-000 |
Discrimination Complaint
Employees who believe they have been discriminated against by their employer may use this form to file a complaint. |
| F262-009-999 |
Queja Por Discriminación
Used by employees who believe they have been discriminated against by their employer may use this form to file a complaint.
|
| F262-013-000 |
Occupational Disease Employment History Hearing Loss
Used by injured worker who has filed an occupational hearing loss claim to report their employment history and the nature of the noise exposure at each job. |
| F262-013-111 |
Occupational Disease Employment History Hearing Loss (Continuation)
Used by injured worker who has filed an occupational hearing loss claim to report their employment history and the nature of the noise exposure at each job. This form is a continuation of form F262-013-000. |
| F262-016-000 |
Occupational Hearing Loss Questionnaire
Used by injured worker who has filed an occupational hearing loss claim to provide more specific information regarding how the hearing loss occurred. This is requested by the Claim Manager and sent to the Injured Worker. |
| F262-016-999 |
Cuestionario Sobre Perdida Del Sentido Auditivo en el Trabajo
Used by injured worker who has filed an occupational hearing loss claim to provide more specific information regarding how the hearing loss occurred. This is requested by the Claim Manager and sent to the Injured Worker. |
| F262-024-000 |
Claim Suppression Complaint
An injured worker may submit this form if their employer has suppressed their right to file an injury claim. |
| F262-024-999 |
Queja por Suprimir un Reclamo - Spanish - Claim Suppression Complaint
An injured worker may submit this form if their employer has suppressed their right to file an injury claim. |
| F262-032-000 |
Targeting Fraud and Abuse in Washington State's Workers' Compensation Program: 2008 Report to the Legislature
Booklet/Pamphlet: Provides an overview of L&I's activities to deter and detect workers' compensation fraud and abuse by workers, employers and medical providers. Includes statistics on dollars collected and costs avoided. |
| F262-249-909 |
Workers' Compensation Discrimination-English/Spanish (Discriminación porque se lesionó en su trabajo)
Fact sheet: Explains workers' legal right to file a workplace injury claim and how to file a complaint if discrimination has occurred. |
| F262-251-000 |
Targeting Fraud and Abuse in Washington State's Worker's Compensation Program: 2005 Report to the Legislature
Booklet/pamphlet: Provides an overview of L&I's activities to deter and detect workers' compensation fraud and abuse by workers, employers and medical providers. Includes statistics on dollars collected and costs avoided. |
| F262-262-000 |
Avoid Liability for Your Subcontractor's Unpaid Workers' Comp Premiums
Fact sheet: Tells construction contractors how to protect themselves from liability for their subcontractor's unpaid workers' compensation premiums. |
| F262-262-999 |
Avoid Liability for Your Subcontractor's Unpaid Workers' Comp Premiums -Spanish (Las primas de compensación para trabajadores no pagadas por su subcontratista podrían ser su responsabilidad)
Fact sheet: Tells construction contactors how to protect themselves from liability for their subcontractor's unpaid workers' compensation premiums. |
| F262-276-000 |
Targeting Fraud and Abuse in Washington State's Workers Compensation Program: 2006 Report to the Legislature
Booklet/pamphlet: Provides an overview of L&I's activities to deter and detect workers' compensation fraud and abuse by workers, employers and medical providers. Includes statistics on dollars collected and costs avoided. |
| F262-279-000 |
Workers' Comp Fraud Hurts YOU
Pamphlet: Explains the impacts of workers' comp fraud and L&I's efforts to prevent and find fraud by workers, employers, contractors, and medical providers. |
| F262-280-000 |
Targeting Fraud and Abuse in Washington State's Workers' Compensation Program: 2007 Report to the Legislature
Booklet/Pamphlet: Provides an overview of L&I's activities to deter and detect workers' compensation fraud and abuse by workers, employers and medical providers. Includes statistics on dollars collected and costs avoided. |
| F280-007-000 |
Plan Development Quality Assurance Review Form
For use internally by L&I Vocational Service Specialists (VSSs) to determine if all required components are included in the submitted plan. Can be used by VRCs as a tool. DO NOT SUBMIT TO L&I. |
| F280-008-000 |
Assessment Eligible Quality Assurance Review Form
For use internally by L&I Vocational Service Specialists (VSSs) to determine if all required components are included in the submitted assessment. Can be used by VRCs as a tool. DO NOT SUBMIT TO L&I. |
| F280-010-000 |
Intent to Hire Preferred Worker
Used by employers when hiring a preferred worker. This form must be received within 60 days of the hiring and the Preferred Worker Employer's Job Description (F280-022-000) form must be attached. |
| F280-011-000 |
Intent to Hire Preferred Worker with Developmental Disabilities
Used by employers rehiring developmentally disabled workers after an industrial injury. This form requests preferred worker status and shows the physical demands of the work to be performed by the worker. The Preferred Worker Employer's Job Description (F280-022-000) should be attached. |
| F280-013-000 |
Plan Development Recommending Plan Approval Routing Sheet
Routing slip that accompanies the Vocational Services Closing Cover Sheet (F252-028-000) which is used to close vocational services to an injured worker only if you are recommending Plan Approval. For all other closing reports, use Vocational Closing Report Routing Sheet (F252-027-000). |
| F280-014-000 |
Assessment Recommending Plan Development Eligible Routing Sheet
Routing slip that accompanies the Vocational Services Closing Cover Sheet (F252-028-000) which is used to close vocational services to an injured worker only if you are recommending Plan Development. For all other closing reports, use Vocational Closing Report Routing Sheet (F252-027-000). |
| F280-016-000 |
Accountability Agreement
This form is for school training plans, must be signed by the worker and VRC and sent in along with your training plan to L&I for approval. For OJT retraining plans, please refer to form F280-029-000.
|
| F280-016-999 |
Accountability Agreement - Spanish (Acuerdo de Responsabilidad
This form must be signed by the worker and the VRC and sent in along with the retraining plan to L&I for approval. |
| F280-017-000 |
Assessing Your Ability to Work: Your Rights and Responsibilities
Booklet: Explains the basics of the assessment phase of vocational services to injured workers. L&I sends this booklet to injured workers when they are referred for assessment services. |
| F280-017-999 |
Assessing Your Ability to Work: Your Rights and Responsibilities -- Spanish (Evaluando su capacidad para trabajar: sus derechos y responsabilidades, Servicios de rehabilitación vocacional)
Booklet: Explains the basics of the assessment phase of vocational services to injured workers. L&I sends this booklet to injured workers when they are referred for assessment services. |
| F280-018-000 |
Plan Development: What Are My Rights & Responsibilities?
Booklet: Explains the basics of the plan development phase of vocational services to injured workers. L&I send this booklet to injured workers when they are referred for plan development services. The assigned vocational rehabilitation counselor is required to review this booklet with the worker at their initial face-to-face meeting. |
| F280-018-999 |
Plan Development: What Are My Rights & Responsibilities -- Spanish (Plan de desarrollo: ¿Cuáles son mis derechos y responsabilidades? Servicios de rehabilitación vocacional)
Booklet: Explains the basics of the plan development phase of vocational services to injured workers. L&I sends this booklet to injured workers when they are referred for plan development services. The assigned vocational rehabilitation counselor is required to review this booklet with the worker at their initial face-to-face meeting. |
| F280-019-000 |
Carrying Out Your Vocational Plan: Your Rights and Responsibilities During Plan Implementation
Booklet: Explains the basics of the plan implementation phase of vocational services to injured workers. L&I sends this booklet to injured workers once the vocational plan they submitted is approved. Information about continuing with the vocational plan or selecting Option 2 to decline retraining is included. |
| F280-019-999 |
Carrying Out your Vocational Plan: Your Rights and Responsibilities During Plan Implementation -- Spanish (Llevando a cabo su Plan vocacional: Sus derechos y responsabilidades
durante el Plan de Implementación, Servicios de rehabilitación vocacional)
Booklet: Explains the basics of the plan implementation phase of vocational services to injured workers. L&I sends this booklet to injured workers once the vocational plan they submitted is approved. Information about continuing with the vocational plan or selecting Option 2 to decline retraining is included. |
| F280-021-000 |
Preferred Worker Program
Pamphlet/booklet: Describes the Preferred Worker Program and the benefits employers receive when hiring a preferred workers. Iin general, these are workers whose work-related injury or occupational disease prevents them from returning to their old job. |
| F280-021-999 |
Preferred Worker Program-Spanish (Programa con incentivos para reemplear trabajadores lesionados)
Pamphlet/booklet: Describes the Preferred Worker Program and the benefits employers receive when hiring a preferred workers. In general, these are workers whose work-related injury or occupational disease prevents them from returning to their old job. |
| F280-022-000 |
Preferred Worker Employers Job Decsription
Used by the employer to describe the job for the preferred worker. This form is reviewed by a vocational services consultant to ensure that the offered job is consistent with the worker's medical restrictions. |
| F280-023-000 |
Request for Preferred Workers Status
Used by vocational providers to apply for preferred worker status in behalf of an industrially injured worker. |
| F280-024-000 |
Option 2 Vocational Benefits Training Enrollment Application and Verification
State fund workers who have selected Option 2 and closed their claim can use this form to apply for access to their Option 2 training funds. To seek reimbursement, use form F245-030-000 Statement for Retraining and Job Modification Services. |
| F280-024-909 |
Option 2 Vocational Benefits Training Enrollment Application and Verification/APLICACIÓN Y VERIFICACIÓN DEL REGISTRO PARA CAPACITACIÓN DE BENEFICIOS VOCACIONALES OPCIÓN 2
State fund workers who have selected Option 2 and closed their claim can use this form to apply for access to their Option 2 training funds. To seek reimbursement, use form F245-030-000 Statement for Retraining and Job Modification Services. |
| F280-025-000 |
Request for Plan Development Extension (State Fund)
For state fund use only. Use this form to request a "good cause" extension to the 90-day requirement during vocational plan development.
Examples of good cause include, but are not limited to:
- A death in the worker's immediate family. For purposes of determining good cause, immediate family is defined as spouse, domestic partner, child, sibling, parent or grandparent.
- Delays caused by documented changes in the worker’s medical ability to participate in plan development.
- Information received by the vocational rehabilitation provider that impacts plan development and was not available when assessment services were provided.
- Documented delay in receipt of requested information from a medical provider relevant to developing the vocational plan.
- The impact of previously identified barriers to employment and/or retraining. |
| F280-029-000 |
On the Job Training Accountability Agreement
This form is for OJT training plans, and must be signed by the worker and VRC then sent in along with your training plan to L&I for approval. For non-OJT retraining plans, please refer to form F280-016-000.
|
| F280-029-999 |
OJT Accountability Agreement ACUERDO DE RESPONSABILIDAD DE LA CAPACITACIÓN DURANTE EL TRANSCURSO DEL TRABAJO (Para planes presentados desde 7/1/08 al 6/30/09)
OJT Accountability Agreement in Spanish |
| F280-032-000 |
OJT Information Request and Recommendation form
VRCs can use this form to request information on a specific on -the -job (OJT) training opportunity listed on L&I's website, or to recommend an OJT training opportunity. |
| F280-033-000 |
Are You an Employer Who Can Provide On-the-Job Training?
Fact sheet: Explains how employers play an important role in helping injured or ill workers return to meaningful employment and a productive life by offering on-the-job training opportunities. |
| F280-036-000 |
Option 2: What You Need to Know, Vocational Rehabilitation Services
Booklet: Explains what happens when an individual selects "Option 2" and choose not to participate in the approved training plan. |
| F280-038-000 |
Vocational Questionnaire/Work History
Vocational Questionnaire/Work History for use by Vocational Providers serving injured workers. |
| F280-039-000 |
On-The-Job Training (OJT) Worksheet for Vocational Providers
On-The-Job Training (OJT) Worksheet for Vocational Providers |
| F413-007-000 |
Application for Asbestos Contractor Certification
Contractors use this form to apply to be a certified asbestos contractor in Washington state. |
| F413-012-000 |
Chemical Hazard Communication: Helpful information for employers
Book: Provides employers a checklist on the requirements of the chemical hazard communication rule. Contains an extensive question-and-answer section and information on starting an employee-training program. |
| F413-012-555 |
Chemical Hazard Communication: Helpful information for employers (Vietnamese)
Book: Provides employers a checklist on the requirements of the chemical hazard communication rule. Contains an extensive question-and-answer section and information on starting an employee-training program. |
| F413-012-777 |
Chemical Hazard Communication: Helpful information for employers (Korean)
Book: Provides employers a checklist on the requirements of the chemical hazard communication rule. Contains an extensive question-and-answer section and information on starting an employee-training program. |
| F413-012-888 |
Chemical Hazard Communication: Helpful information for employers (Chinese)
Book: Provides employers a checklist on the requirements of the chemical hazard communication rule. Contains an extensive question-and-answer section and information on starting an employee-training program. |
| F413-012-999 |
Comunicación sobre Peligros Químicos: Información útil para los empleadores
Book: Provides employers a checklist on the requirements of the chemical hazard communication rule. Contains an extensive question-and-answer section and information on starting an employee-training program. |
| F413-014-909 |
Workers' Guide to Hazardous Chemicals: Understanding the Right-to-Know Law-English/Spanish (Guía del trabajador para el uso de químicos peligrosos: Comprendiendo la Ley del derecho a saber)
Pamphlet/booklet: Explains Washington's chemical hazard communication standard, which requires employers to inform their employees about hazardous chemicals in the workplace and to train them in their proper use. |
| F413-024-555 |
Your Body, Your Job: Preventing Carpal Tunnel Syndrome and Other Upper Extremity Musculoskeletal Disorders (Vietnamese)
Pamphlet/booklet: Reviews the symptoms and risk factors for carpal tunnel syndrome and several other musculoskeletal disorders that affect the shoulder, arm and elbow. Discusses prevention approaches and where to get more information. |
| F413-024-999 |
Su cuerpo, su empleo: Prevención del Síndrome del Túnel Carpiano y otras lesiones músculo esqueléticas de las extremidades superiores
Pamphlet/booklet: Reviews the symptoms and risk factors for carpal tunnel syndrome and several other musculoskeletal disorders that affect the shoulder, arm and elbow. Discusses prevention approaches and where to get more information. |
| F413-025-000 |
Asbestos Abatement Project Notice of Intent and L&I DOSH Asbestos Program
Notice is not required for any asbestos project involving less than forty-eight (48) square feet of surface area, or less than ten (10) linear feet of pipe unless the surface area of the pipe is greater than forty-eight (48) square feet. Get instructions to complete the form.
|
| F413-045-000 |
Poison Oak Poster (English/Spanish)
Full-color photographs of poison oak in different seasons help workers recognize and avoid the plant when working outdoors. Note: Poster will split over two pages if printed on 8.5" X 11" paper. Get poster printing tips. |
| F413-047-000 |
Protecting Yourself and Your Workers from Poison Oak and Ivy (English/Spanish)
Pamphlet/booklet: Discusses the effects of poison oak and ivy, where it is found in Washington State, how to control growth and protect workers from exposure. |
| F413-049-000 |
Working Safely with Asbestos in Brake and Clutch Linings
Pamphlet/booklet: Reviews the health hazards of asbestos exposure, use of asbestos in brake and clutch linings, employer's responsibilities, how employees can protect themselves, employee rights, and where to get help with waste management. |
| F413-060-000 |
Your Lungs, Your Work, Your Life: What You Should Know about Work-related Asthma
Pamphlet/booklet: Briefly reviews the symptoms and causes of work-related asthma and explains prevention and treatment approaches. |
| F413-060-444 |
Your Lungs, Your Work, Your Life: What You Should Know about Work-related Asthma (Russian)
Pamphlet/booklet: Briefly reviews the symptoms and causes of work-related asthma and explains prevention and treatment approaches. |
| F413-060-999 |
Sus Pulmones Su trabajo Su vida: Lo que debería saber acerca del asma ocupacional
Pamphlet/booklet: Briefly reviews the symptoms and causes of work-related asthma and explains prevention and treatment approaches. |
| F413-062-000 |
Cholinesterase Monitoring Reimbursement Request
Employers use this form to request reimbursement for the reasonable costs of training, travel, recordkeeping, and medical expenses for Cholinesterase Monitoring. |
| F413-064-000 |
Cholinesterase Blood Testing Choice
Use this form to say whether or not you choose to have the Cholinesterase blood tests performed. |
| F413-064-999 |
Elección para Prueba de Sangre de Colinesterasa
Use this form to say whether or not you choose to have the Cholinesterase blood tests performed. |
| F413-065-000 |
Cholinesterase Monitoring Handling Hours Report
Employers must complete this form for the employee for each periodic/follow-up test and provide a copy to the health care provider. |
| F413-068-000 |
Application for Replacement of Lost or Stolen Asbestos Certification Card
This application is for any certified asbestos worker or supervisor that has lost or had their card stolen. |
| F413-070-000 |
Cholinesterase Monitoring Health Care Provider Recommendations
Filled out by the provider. This form gives the recommendations by the provider of what needs to be done based on the test results on the employee. |
| F413-070-999 |
Monitoreo de la Colinesterasa Recomendaciones del Proveedor Medico formulario muestra
Filled out by the provider. This form gives the recommendations by the provider of what needs to be done based on the test results on the employee.
|
| F413-075-000 |
Worker and Community Right-to-Know Program
Fact sheet: Provides an overview of the Worker and Community Right-to-Know (RTK) Program authorized by legislation in 1986. Explains the RTK fees, education on hazardous substances that the fees support, who pays the fees and how they are calculated. |
| F414-021-000 |
Variance Application - IND S&H
Use this form to apply for a variance for an allowed deviation from a specific safety or health standard when an employer substitutes measures which afford an equal degree of safety. |
| F414-074-034 |
Workplace Safety and Health Rules
CD: Contains workplace safety and health rules for Washington State and links to policies and related laws. Also contains guides covering accident prevention programs (APP) and personal protective equipment (PPE). Note: Order CD or view rules online. |
| F416-011-000 |
Safety and Health Discrimination Complaint
Use this form to file a complaint when you feel you've been discriminated against or discharged for reporting a workplace safety hazard. |
| F416-011-999 |
Queja De Discriminacion Sobre Salud Y Seguridad En El Lugar De Trabajo
Si Usted piensa que ha sido discriminado o despedido por reportar los peligros existentes en su lugar de trabajo, utilice este formulario para presentar una queja. |
| F416-016-000 |
Statement
This form is predominately used in non-accident related types of inspections. Used to obtain statements from employees or other individuals whenever it is determined that it would be useful to adequately document an apparent violation. |
| F416-034-000 |
Application for Charter Boat Operators License
Use this form to apply for an operators license of a charter vessel. |
| F416-036-000 |
Reduce Your Costs at No Cost
Pamphlet: Introduces free workshops to help employers prevent workplace injuries and control workers' compensation costs. Includes course descriptions, where you can find current schedules, and how to register. |
| F416-042-000 |
Mobile Cranes/Derricks Supplemental Component Worksheet
|
| F416-043-000 |
Mobile Cranes/Derricks Worksheet for Construction Industry
Mobile Cranes/Derricks Worksheet for Construction Industry |
| F416-044-000 |
Tower Crane Worksheet for Construction Industry
|
| F416-051-000 |
Cranes, Derricks or Material Handling Devices Worksheet for Maritime Industry
Use this form for the inspection of cranes, derricks and materials handling devices on waterfront operations |
| F416-052-000 |
Bulk Cargo Spouts, Suckers and Similiar Equipment for Maritime Operations
Use this form for the inspection of spouts, suckers and similar equipment on waterfront operations |
| F416-054-000 |
Notice of Deficiencies
Use this form for noting any deficiencies of cranes, derricks, material handling devices, spouts, suckers and similar equipment. |
| F416-056-000 |
Physical Exam - Charter Boat Operators License
This form is used by applicants applying for a charter boat operators license to have completed by a physician for an operators license |
| F416-058-000 |
Charter Vessel Inspection
Two part form used for the applicant to complete a Certification of Inspection of a charter boat and the second part is used for the Maritime Specialist to perform the inspection of the charter boat. |
| F416-063-000 |
Applicatiion for Accreditation Cranes/Derrick and other Material Handling Devices
This form is for an applicant to complete for Maritime or Construction Accreditation. |
| F416-081-444 |
Job Safety and Health Law poster (Russian)
Poster: Required in English, recommended in Russian for work sites with Russian-speaking workers. Describes important parts of the Washington Industrial Safety and Health Act (WISHA), which provides for job safety and health of Washington employees. Get poster printing tips. |
| F416-081-777 |
Job Safety and Health Law poster (Korean)
Poster: Required in English, recommended in Korean for work sites with Korean-speaking workers. Describes important parts of the Washington Industrial Safety and Health Act (WISHA), which provides for job safety and health of Washington employees. Get poster printing tips. |
| F416-081-909 |
Job Safety and Health Law-English/Spanish (Ley de seguridad y salud en el trabajo)
Required poster: Describes important parts of the Washington Industrial Safety and Health Act (WISHA), which provides for job safety and health of Washington employees. Note: Employers in Washington State must display this poster where workers can see it. When ordering the printed version, you will receive one 22" X 17" poster that includes both languages. Get poster printing tips. |
| F416-087-000 |
Application for Permit to Operate Radio System in Designated Area
This form is used by the logging industry to apply for a permit to operate a radio signal system. |
| F416-093-000 |
Witness Statement
Use this form only on accident investigations, fatalities and catastrophies. This form is used to obtain statements from the witness to the accident or personnel who did not witness the accident but have information regarding the incident. |
| F416-132-000 |
A Guide to WISHA
Pamphlet/booklet: Provides an overview of the Washington Industrial Safety and Health Act (WISHA), worker and employer rights and responsibilities, and consultation and compliance services L&I provides. NOTE: Pages 4 and 8 and back cover updated March 2009 to reflect the change in hospitalization reporting requirement that took effect April 2008. |
| F416-132-999 |
A Guide to WISHA-Spanish (Guía de WISHA, el programa de seguridad y salud para el lugar de trabajo del estado de Washington)
Pamphlet/booklet: Provides an overview of the Washington Industrial Safety and Health Act (WISHA), worker and employer rights and responsibilities, and consultation and compliance services L&I provides. NOTE: Pages 4 and 8 and back cover updated March 2009 to reflect the change in hospitalization reporting requirement that took effect April 2008. |
| F417-014-000 |
Logging Emergency Medical Plan (Logging Safety and Health Meetings)
Use this two part form for employers to record work locations and emergency rescue info and for holding safety meetings for each new jobsite |
| F417-031-000 |
Forklift Safety Guide
Book: Provides general information on kinds of forklifts, principles of physics that apply to forklifts, training requirements for forklift operators, basic operator safety rules, dangers of carbon monoxide, and safety while servicing a forklift. |
| F417-043-000 |
Guide to Crew Safety Meetings
Pamphlet/booklet: Provides a succinct guide to conducting crew safety meetings for general industry and the construction industry. Includes a format for recording meeting minutes. |
| F417-048-000 |
Supervisor's Report of an Accident
Supervisors use this form to document information from an accident or injury. |
| F417-049-000 |
Crew Leader Safety Meeting
Use this form to document the minutes of your safety meetings. |
| F417-055-909 |
Quick Tips for Lifting-English/Spanish (Consejos breves para levantar cargas)
Fact sheet: Provides 10 tips for safer lifting. Contains illustrations. |
| F417-061-000 |
Safety and Health Video Library
Online: Lists more than 2500 videos (VHS and DVD formats) on topics pertaining to occupational safety and health - everything from forklift safety to workplace violence prevention. Just perfect for safety meetings or committees. Complete information for borrowing procedures and setting up a free video library account with L&I at this link.
|
| F417-067-000 |
Safety & Health Program Assessment Worksheet
For use by consultants to evaluate employers' accident prevention programs. Use this form for large employers (more than 50 employees). |
| F417-067-111 |
Safety & Health Program Assessment Worksheet
For use by consultants to evaluate employers' accident prevention programs. Use for businesses with less than 50 employees). |
| F417-087-000 |
Safety Meeting Minutes
Use this form to record the minutes from your safety meetings - these records must be retained for one year from the date of each meeting |
| F417-092-000 |
Guidelines for Selecting Reserve Trees
Book: Provides technical guidance on retaining reserve trees in concert with safe work practices and forest and wildlife management goals. Produced cooperatively by state and federal agencies and industry groups. |
| F417-102-000 |
Competent Person Evaluation - Fall Restraint & Fall Arrest
The employer uses this checklist to determine the person they have designated as a competent person is competent within the description and intent of the fall restraint and fall arrest stanard. |
| F417-104-000 |
Competent Person Evaluation - Excavation & Trenching
The employer uses this checklist to determine the person they have designated as a competent person is competent within the description and intent of the excavation and trenching standards. |
| F417-107-000 |
Fall Protection Work Plan Requirements
This booklet defines the work plan requirements you must meet for fall protection. |
| F417-129-000 |
Lessons for Lifting & Moving Materials
Book: Identifies work areas, tasks and procedures that place employees at risk of injury. Describes and illustrates methods that help reduce the risk of injury. |
| F417-133-000 |
Office Ergonomics: Practical solutions for a safer workplace
Book: Provides information and tools to analyze office jobs, find problems and develop ergonomic solutions. |
| F417-140-000 |
Workplace Violence: Awareness and Prevention for Employers and Employees
Book: Describes four types of workplace violence, outlines steps to minimize and prevent violent acts, and discusses potential risk factors and prevention techniques. Includes a sample program and reproducible forms. |
| F417-150-000 |
Accident Prevention Program Analysis
This form is used to analyze accident prevention programs for your business. This is only available online. |
| F417-150-002 |
Accident Prevention Program Analysis (Continued)
This continuation form is used to analyze accident prevention programs for your business. |
| F417-188-909 |
Employee Discrimination Protection (English/Spanish)/ Protección Para Empleados Contra La Discriminación
Poster: Employees have the right to report concerns about safety and health in their workplace. This poster describes "protected activities" under the Washington Industrial Safety and Health Act (WISHA) and explains what an employee should do if he/she has been punished or fired for exercising these rights. Get poster printing tips. |
| F417-195-000 |
Pocket Guide to Caution Zone Jobs
Pamphlet/booklet: This advisory pocket guide reviews 14 workpalce risk factors that can lead to soft tissue injuries such as back strain, tendinitis and carpal tunnel syndrome. Suggests ways to identify the risk factors. Lists helpful resources from L&I.
|
| F417-196-000 |
Lumber Handling in Sawmills
Book: Developed by mill workers, mill managers and L&I, this manual describes the risks of musculoskeletal injury in lumber-handling jobs. Identifies controls to reduce hazards,increase efficiency and reduce injuries. |
| F417-202-000 |
Forklift Training Facts
Fact sheet: Provides answers to the most-often asked questions about forklift training. Includes a checklist that employer may use to document that employees have been trained and/or evaluated in the required topics. |
| F417-205-000 |
Borrower Agreement Form Safety and Health Video Library
Borrower Agreement Form - To open an account and borrow videos, please fill out this form. |
| F417-206-000 |
Reservation Form Safety and Health Video Library
Use this form to make reservations of safety and health videos. |
| F417-207-000 |
Personal Protective Equipment (PPE) Guide
Book: This guide helps employers comply with the WISHA Personal Protective Equipment rules. It covers general personal protective equipment and PPE requirements used to protect the head, eyes and face, hand and arm, foot and leg, and body (torso) in most work environments. |
| F417-208-000 |
Fall Protection: Responding to Emergencies
Book: This guide is for employers and for employees who work from exposed, elevated surfaces. It covers the following: what to do to prevent fall-related emergencies and how to respond promptly if a fall-related emergency occurs. Includes illustrations of aided-rescue equipment systems. |
| F417-209-000 |
Say Yes! To a Safe Workplace, to a Free Consultation
Pamphlet/booklet: Describes the benefits of free employer consultations offered by L&I's Division of Occupational Safety and Health (DOSH). These services include on-site safety and/or industrial hygiene consultations, ergonomics assistance and risk management advice. |
| F417-209-999 |
Say Yes! To a Safe Workplace, to a Free Consultation-Spanish (¡Diga Sí! A un lugar de trabajo seguro, a una consulta gratis)
Pamphlet/booklet: Describes the benefits of free employer consultations offered by L&I's Division of Occupational Safety and Health (DOSH). These services include on-site safety and/or industrial hygiene consultations, ergonomics assistance and risk management advice. |
| F417-213-909 |
Jorge's New Job: Cholinesterase Testing in Washington State (English/Spanish)
Pamphlet/booklet: Uses a story format with dialogue and photographs to explain the hazards of cholineserase-inhibiting pesticides, the state's monitoring program and the importance of using proper safety equipment when working with pesticides. |
| F417-214-000 |
Protect Yourself and Your Family from Lead Poisoning
Pamphlet/booklet: Explains the risks of lead exposure for workers who work on outdoor steel structures, and harmful effects on workers and their families. It includes a poster about the importance of safe work practices and procedures. |
| F417-218-909 |
Heat-related Illness Education Card/Tarjeta de educación sobre enfermedades relacionadas con el calor (English/Spanish)
Identifies the effects of heat exhaustion and heat stroke on the body and what to do if you observe symptoms. Reviews prevention steps. PDF file is set up for two copies to print at one time. |
| F417-221-000 |
Voluntary Protection Program (VPP)
Fact sheet: Provides an overview of the VPP, a program that recognizes occupational safety and health excellence. Identifies benefits and includes testimonials from companies awarded VPP status. |
| F417-222-000 |
Safety & Health Video Library & Resource Center
Pamphlet: Introduces the center and available services. You can borrow safety training videos and DVDs and order workplace posters. Also contains contact information. |
| F417-224-000 |
Safety and Health Investment Projects (SHIP) Grant Program
Pamphlet/booklet: Introduces the SHIP Grant Program and application process. Eligible grants will aim to prevent injuries and illnesses, save lives, and educate workers and employers about workplace hazards and safe workplace practices.
Proposals submitted by applicants |
| F418-023-000 |
Application for Copies of Citation and Notice
Used by an employee to apply for copies of citation and notices issued to their employer. |
| F418-031-000 |
Hazard Documentation Worksheet
Hazard Documentation Worksheet for use by L&I compliance staff to describe, measure and comment on workplace hazards. |
| F418-052-000 |
Alleged Safety Or Health Hazards (DOSH Complaint Form)
Employees use this form to report work place conditions which jeopardize workers safety and health. |
| F418-052-999 |
Presuntos Riesgos de Salud y Seguridad - Alleged Safety Or Health Hazards (DOSH Complaint Form) - Spanish
Employees use this complaint form to report work place conditions which jeopardize workers safety and health. |
| F418-055-000 |
Construction Checklist - Safety
Construction Checklist - Safety |
| F418-055-999 |
Construction Checklist - Safety - Spanish - Lista de verificación de seguridad en la construcción
Construction Checklist - Safety - Spanish - Lista de verificación de seguridad en la construcción |
| F500-010-000 |
Application for Amusement Ride or Air Supported Structure Operating Permit
To apply for a decal for an amusement ride or air supported structure. |
| F500-018-000 |
Application for Electrical Contractors License
Application used to get an electrical contractors license |
| F500-019-000 |
Electrical/Telecommunications Contractor's Bond to the State of WA
Used to show proof of a bond in the State of Washington. |
| F500-020-000 |
Electrical/Telecommunications Contractor Assignment of Savings Account
This is used to assign ownership interest to a savings account that is held by L&I for one year after a contractor's license has expired or after the contractor ceases business in Washington State. |
| F500-025-000 |
Agency Requested Inspection
Used by non-L&I agencies and jurisdictional authorities to request an inspection on an electrical harzard. |
| F500-032-000 |
Request for Duplicate License or Certificate
To request a duplicate of your Washington state electrical license or certificate. |
| F500-039-111 |
Chapter 19.28 RCW - Electricians and Electrical Installations - (effective 06/06/2006)
Simplified version of the Chapter 19.28 RCW - Electricians and Electrical Installations Rules |
| F500-039-222 |
Electrical Safety Standards,Administration, and Installation WAC 296-46B
Electrical Safety Standards,Administration, and Installation WAC 296-46B
|
| F500-043-000 |
Affidavit of Experience
This affidavit is used to record the hours of a trainee's electrical experience with direct supervision under a Washington certified journeyman, master or specialty electrician. |
| F500-044-000 |
Request for Change of Address
Used by electrical licensee to notify L&I of an address change. |
| F500-045-000 |
Administrator / Electrician / Master Electrician Certificate Renewal
To renew your electrical certificate. Fee varies depending on renewal type. |
| F500-054-000 |
Application to Establish an Account and Access to L&I's Electrical Permit & Inspection System (EPIS) with L&I's Miscellaneous Accounts
To request access to L&I's EPIS - Miscellaneous Accounts |
| F500-055-000 |
Application to Access L&I's Electrical Permit and Inspection System (EPIS) from SecureAccess Washington and Utilize Contractor Deposit Account via the Internet
To establish a contractor deposit account by an electrical contactor or registered construction contractors who are legally required to purchase electrical work permits from L&I. |
| F500-062-000 |
Request to Perform Electrical Product Field Evaluation
The approval of this request to perform field evaluations will depend on the submitters meeting all the requirements of RCW 19.28. All requests must be submitted to L&I in writing at least 2 working days (48 hrs) prior to the project inspection date. |
| F500-063-000 |
Electrical Installation Variance Application
To apply for a variance which is an allowable deviation from specific requirements of a National Electrical Code section, or the WAC 296-46B where the proposed alternate methods will maintain equivalent safety. |
| F500-065-000 |
Application for Amusement Ride Inspector Certification
Application to be certified as an amusement ride inspector. |
| F500-066-000 |
Affidavit for Amusement Rides
Affidavit of experience to apply for cetification as a Amusement Ride Inspector. |
| F500-068-000 |
Electrical Education Course Application
Used to get approval of a course as an electrical continuing education class. This application must be received by L&I at least 30 days before the course is offered. |
| F500-072-000 |
Reassignment of Savings Account or Time Deposit - Electrical Contractor
A reassignment is permitted only when (1) the Electrical Contractor (assignor) changes the name of the business; (2) the Electrical Contractor transfers the funds to a new account; or (3) the financial institution changes the account number. |
| F500-074-000 |
Electrical Work Permit Refund Request
To apply for an electrical work permit refund. Online only. |
| F500-076-000 |
Investigation Report
To notify L&I on any electrical work that you think is illegal. |
| F500-077-000 |
Electrical / Telecommunication Contractor's License Renewal Notice
This form is used to notify you that your license will expire and for you to use to renew your license. |
| F500-078-000 |
Electrical Work on Residential Property: What You Should Know Before Work Begins
Fact Sheet: Explains to property owners the importance of electrical permits, inspections and approvals. An electrical permit is required for most new, remodel and maintenance electrical work. |
| F500-080-000 |
Account Deposit for Contractor's or Miscellaneous Account Holder's
Used to deposit money into your L&I account (Electrical). |
| F500-087-000 |
Electrical Inspection Witness Statement
Used to gather information from a person who was a witness to electrical work that is being investigated by L&I. |
| F500-088-000 |
Application for Master Electrician Certification Examination
Use this form to apply for the master electrician exam. |
| F500-090-000 |
Electrical Continuing Education Instructor Application
An application to receive approval from L&I to instruct electrical continuing education courses. |
| F500-093-000 |
Contractor Electrical Work Permit Application
This application is used to apply for a valid electrical permit from L&I. 4 pages. |
| F500-094-000 |
Property Owner Electrical Work Permit Application
This application is used to apply for a valid electrical permit. 5 pages. |
| F500-097-000 |
Applicaton for an E2- 0% Supervision Modified Electrical Training Certificate & Specialty Examination
Covers 03A, 06B, 07A, 07B, 07C, 07D, 07E, and 10 specialty licenses. |
| F500-098-000 |
Application for Specialty Electrician Certificate
Application and instructions for the specialty electrician certificate for 03A, 06B, 07A, 07B, 07C, 07D, 07E and 10. Eligibility granted through modified supervision requirements of RCW 19.28.191(1)(g)(ii) |
| F500-099-000 |
Application for a E3-75% Supervision Modified Electrical Training Certificate
Required if 3A, 6B, 7A, 7B, 7C, 7D, 7E, or 10 and have not completed the modified training requirements to receive specialty electrician cerfitication. |
| F500-101-000 |
Application for Accreditation of Engineer to Approve Industrial Utilization Equipment
Used by an Engineer to apply for accreditation by L&I to approve unlisted equipment. |
| F500-104-000 |
Application for Pump Installer Combination General Contractor Registration and Electrical Contractor License
Used for creating combination electrical and plumbing contractors license |
| F500-109-000 |
Electrical Work on Commercial Property: What You Should Know Before Work Begins
Fact Sheet: Explains to commercial property owners the importance of electrical permits, inspections and approvals. An electrical permit is required for most new, remodel and maintenance electrical work. |
| F500-110-000 |
Questions and Answers about Electrical Safety
Fact Sheet: Answers questions about training and certification/licensing requirements for those who perform electrical installations, and electrical work that requires a permit and inspection. |
| F500-111-000 |
Before Electrical Sign Work Begins: What Electrical Sign Contractors and Electricians Should Know
Fact Sheet: Explains work that is allowed and not allowed under (04) Sign Scope of Work and what electrical sign contractors and electricians should know before doing sign work. Also covers electrical Class B labels and electrical permits, inspections and fees. |
| F500-112-000 |
Class B Labels: What You Should Know
Fact Sheet: Explains Class B label electrical work, scope and limitations, and provides general instructions for using Class B labels. |
| F500-113-000 |
Online Electrical Services: Tools for Property Owners, Contractors and Electricians
Fact Sheet: Describes the online services available from L&I's Electrical Program, including URLs for different topics covered on the Web, how to sign up for the Electrical listserv (to receive updates by e-mail), and how to sign up for the monthly e-newsletter, also provided by e-mail. |
| F500-114-000 |
Electrical Program Contacts
Fact Sheet: Provides information for requesting electrical inspections, including telephone numbers and locations of L&I offices that handle electrical inspections. |
| F500-115-000 |
Electrical Safety Tips for Your Home: Protect Your Family and Your Property
Pamphlet/Booklet: Provides information to help consumers properly handle electrical equipment and appliances, know the required permits and inspections for electrical work, and verify licenses and certifications before having electrical work performed. |
| F500-116-000 |
Green Power Generation System Installation: What You Should Know Before Doing Any Electrical Work
Fact sheet: Explains that an electrical permit and inspection are required for most new, remodel, and maintenance electrical work. Provides information specific to the installation of green power generation systems. |
| F500-117-000 |
How to Become a Certified Electrician: What You Need to Know about Certification in Washington State
Fact sheet: Provides information about getting a trainee card and outlines the electrical training and experience required to be certified as an electrician in Washington State. |
| F503-008-000 |
Application for Telecommunications Contractor's License
Application used to get an telecommunications contractors license. |
| F503-009-000 |
Change Assignment of Administrator/Master Certificate
To assign or unassign your status as an administrator or master. |
| F620-012-000 |
Non-Compliance Report - Boiler & Pressure Vessel Inspection
Used by L&I inspectors when a boiler or pressure vessel does not pass inspection. You can only mail or fax this form to L&I. E-mailed forms are NOT accepted. |
| F620-017-000 |
Board of Boiler Rules Interpretation and Revision Request Form
Used to submit written requests for interpretations and revisions to the definitions, rules and regulations found in WAC 296-104. These must be submitted 45 days prior to the Board of Boiler Rules Meeting date. To use this form, left click on the link and select SAVE TARGET AS and save to your desktop. Open in WORD, complete form, select PRINT, SEND TO, MAIL or DELIVERY DOCUMENT ONLY in care of Chief, Boiler Inspector. |
| F620-025-000 |
Operating Boilers Safely
Fact sheet: Explains what you need to know to keep your boilers and pressure vessels operating safety. Provides an overview of inspection requirements, frequency and fees. |
| F620-027-000 |
Shop and Field Inspection Report
Used by L&I inspectors when they inspect boilers. |
| F620-032-000 |
Boiler / Pressure Vessel Installation or Reinstallation Permit
Click on the link at the top of the form to get instructions. This form is filled out by the installer, contractor and/or owner who wants to install or reinstall a boiler. 1 permit per object. E-mailed forms are preferred method of submission. To use this form, left click on the link and select SAVE TARGET AS and save to your desktop. Open in WORD, complete form, select PRINT, SEND TO, MAIL DOCUMENT AS ATTACHMENT to email form to Boilers. |
| F620-036-000 |
Monitoring Q.A./Q.C. Programs Record
L&I Inspection report on the QA/QC manual of a company regarding boilers. |
| F620-037-000 |
Boiler Section QA/QC Monitoring Schedule
The monitoring schedule of the QA/QC of boilers by L&I inspectors and notes if in-compliance or not in compliance. |
| F620-040-000 |
Application for Certificate of Competency as an Inspector of Pressure Retaining Items
To apply for a certificate of competency as an Inspector of Pressure Retaining items. You can only mail or fax this form to L&I. E-mailed forms are not accepted.
NOTE: Applications MUST be received no later than 30 days prior to the exam date
Incomplete applications WILL NOT be accepted. |
| F620-041-000 |
Boiler/Pressure Vessel Clearance Variance Request
To request a clearance variance on a boiler or pressure vessel. You can only mail or fax this form to L&I. E-mailed forms are not accepted. |
| F620-042-000 |
Rental Boiler Operating Permit - Good at this Location Only
To request a permit to use a rental boiler at one location only. |
| F620-043-000 |
Historical Boilers Inspection Guideline
Inspection sheet for boiler inspectors. 4 pages. |
| F620-044-000 |
Incident Report Boiler or Pressure Vessel
Used for the reporting of incident with boilers or a pressure vessels. |
| F620-048-000 |
Keep Your Water Heater Safe
Pamphlet/booklet: Describes the process for conducting an annual safety test of a residential water heater. Includes illustrations. |
| F620-050-000 |
Pre-Inspection Checklist for Hot Water Heating or Hot Water Supply Boilers
Checklist which reflects the most common violations encountered by Field Inspectors. This checklist should be gone through prior to requesting inspection of Hot Water Heating or Hot Water Supply Boilers |
| F620-051-000 |
Pre-Inspection Checklist for Potable Water Heaters - HLW
Checklist which reflects the most common violations found by Field Inspectors. This checklist should be gone through prior to calling for an inspection of Potable Water Heaters-HLW |
| F620-052-000 |
Pre-Inspection Checklist for Low Pressure Steam Boilers
Checklist which reflects the most common violations found by Field Inspectors. This checklist should be gone through prior to calling for an inspection of Low Pressure Steam Boilers |
| F620-053-000 |
Pre-Inspection Checklist for High Pressure Boilers
Checklist which reflects the most common violations found by Field Inspectors. This checklist should be gone through prior to calling for an inspection of High Pressure Boilers |
| F620-054-000 |
Boiler Inspector's Ride Along Audit Checklist
Checklist used during a Boiler Inspector's Ride Along to determine if proper procedures are being followed. |
| F620-055-000 |
Board of Boiler Rules Extension of Inspection Frequency Request Form
Board of Boiler Rules Extension of Inspection Frequency Request Form |
| F620-056-000 |
Chief Inspector Clarification and Interpretation Request Form
Chief Inspector Clarification and Interpretation Request Form |
| F620-057-000 |
Board of Boiler Rules Washington State Specials Request Form
Board of Boiler Rules Washington State Specials Request Form |
| F621-001-000 |
Construction Elevator Installation Application and Inpection Data Report
Used by companies to apply for an Construction Elevator (Hoist) at a job site. One application per car and companies need to contact the Elevator Section for the appropriate installation and operating fee. |
| F621-005-000 |
Installation Application for Elevators
Used for installation application for elevators (new, renewals, and alterations) |
| F621-046-000 |
Test Log for Periodic Inspections & Tests for Hydraulic Elevators
ASME A17.1 requires periodic tests on various types of elevator equipment. This form is used as documentation to test hydraulic elevators. |
| F621-047-000 |
Test Log for Periodic Inspections & Tests for Traction Elevators
ASME A17.1 requires periodic tests on various types of elevator equipment. This form is used as doucmentation to test traction elevators. |
| F621-048-000 |
Elevator Installation Variance Application
Property owner or elevator company can apply for a variance to install an elevator. 4 pages. |
| F621-050-000 |
Elevator Information Update
This form is required by L&I before they can process any changes to the ownership, physical or mailing address. |
| F621-051-000 |
Elevator Five-Year Safety Test Report
This report is used by L&I for its five-year safety inspection of an elevator. |
| F621-052-000 |
Hydraulic Overpressure Test
To be submitted when a valve is changed or a seal is broken. |
| F621-053-000 |
Extension Request
This form is to request a time extension from an unforeseen circumstances for overdue corrections for conveyances. |
| F621-055-000 |
Test of Escalator Safety Devices
A licensed elevator mechanic shall perform this test once a year and mail a copy to L&I. |
| F621-056-000 |
Conveyance Installation Approval by Building Official
Used by the installer to notify L&I that a conveyance is proposed for installation in a buildiing. |
| F621-057-000 |
Elevator/General/Specialty Contractor Responsibility on New Installations
Checklist for the elevator company/contractor to complete before the call L&I for an elevator inspection. |
| F621-063-000 |
Owner Requested Red Tag Form
Used by the owner for red tagging a unit that is to be placed or to remain out of service. |
| F621-065-000 |
Request for Duplicate Elevator Certificate
Used to request a duplicate elevator license or a duplicate operating permit for a conveyance. |
| F621-066-000 |
Elevator Refund Request
To request a refund of the fee paid for an elevator permit. |
| F621-067-000 |
Application for Licensure as an Elevator Mechanic
This is an application for certification as an Elevator Mechanic and is NOT a license to perform work.
A contractor's license is still required by L&I. |
| F621-068-000 |
Temporary Licensed Elevator Mechanic
This temporary license is limited to the mechanical and electrical operation, construction, installation, alteration, maintenance, inspection, relocation and repair of conveyances. |
| F621-069-000 |
Licensed Elevator Contractor (LC) Operation
Contractors who install, construct, repair, alter or maintain elevators need to be licensed by the Elevator Program through L&I and with L&I's contractor registration program. |
| F621-070-000 |
License Requirements for Elevator Mechanics and Contractors
Fact sheet: Explains licensing and testing requirements for mechanics who work on elevators and for contractors who install, repair or maintain elevators. |
| F621-077-000 |
Elevator Continuing Education Course Application
This is used to apply for approval of elevator related continuing education courses. |
| F621-078-000 |
Elevator Continuing Education Instructor Application
Application to become an instructor for elevator related courses. |
| F621-080-000 |
Renewal of Elevator Mechanic License
Used by elevator mechanics to renew their license if they do not want to use the on-line "Get or Renew a License". |
| F621-082-000 |
Renewal of Contractor Elevator License
Used by Elevator Companies to renew their Contractor License. |
| F621-084-000 |
How to Ride Safely on Elevators, Escalators and Moving Walks
Pamphlet/booklet: Provides safety tips and interesting facts to promote safe use of elevators, escalators and moving walks. |
| F621-086-000 |
Change/Update Elevator Company Primary Point of Contact
Used by the Elevator Section only to Change and/or Update the Primary Point of Contact for Elevator Companies |
| F621-094-000 |
APPLICATION TO ACCESS L& I’S ELECTRONIC PERMIT & INSPECTION SYSTEM (EPIS) FROM SECUREACCESS WASHINGTON AND UTILIZE CONTRACTOR DEPOSIT ACCOUNT VIA THE INTERNET
|
| F621-095-000 |
Change Assignment of Primary Point of Contact
Change Assignment of Primary Point of Contact |
| F621-098-000 |
ELEVATOR
ACCOUNT DEPOSIT FOR CONTRACTOR’S OR
MISCELLANEOUS ACCOUNT HOLDER’S
ELEVATOR
ACCOUNT DEPOSIT FOR CONTRACTOR’S OR
MISCELLANEOUS ACCOUNT HOLDER’S
|
| F621-099-000 |
Request for Duplicate Elevator Mechanic License
Request for Duplicate Elevator Mechanic License |
| F621-100-000 |
Elevator Mechanic and Elevator Temporary Mechanic Address/Mailing Information Update
Elevator Mechanic and Elevator Temporary Mechanic Address/Mailing Information Update |
| F622-006-000 |
Plan Approval Request - Recreational Vehicles and Recreational Park Trailers
Plans to build recreational vehicles or park trailers need approval from L&I. This form is used as part of the approval process. |
| F622-011-000 |
Alteration Fire Safety Pre-Inspection Checklist
Checklist for homeowners on how to upgrade their pre-HUD homes to approach the HUD
standards in the area of fire safety. |
| F622-011-999 |
Alteration Fire Safety Pre-Inspection Checklist -Spanish
Checklist for homeowners on how to upgrade their pre-HUD homes to approach the HUD standards in the area of fire safety. |
| F622-013-000 |
Electric / Gas Conversion Pre-Inspection Checklist
This checklist is generic in content and may not include all requirements for your particular installation. The manufacturer's installation instruction must be adhered to and available to the inspector at the time of the inspection. |
| F622-014-000 |
Air Conditioner / Heat Pump Pre-Inspection Checklist
This checklist is designed to be generic in content and may not include all requirements for your particular installation. |
| F622-015-000 |
Wood / Pellet Stove / Fireplace Pre-Inspection Checklist
This checklist is designed to be generic in content and may not include all requirements for your particular installation. |
| F622-021-000 |
Application for State Plan Insignia for Recreational Vehicles and Recreational Park Trailers
To apply for an insignia for a recreational vehicle. |
| F622-021-111 |
Insignia Continuation Sheet Recreational Vehicles and Park Trailers
Continuation sheet to apply for an insignia. |
| F622-035-000 |
Plan Approval Request - Conversion Vendor / Medical Units
Used in requesting a plan approval for Conversion Vendor or Medical Unit factory-assembled structures. |
| F622-036-000 |
Factory Assembled Structures Alteration Application
Used by a homeowner or contactor to request a field inspection for an alteration to a manufactured or mobile home. |
| F622-038-000 |
Low Voltage Fire / Intrusion Alarm Checklist
This checklist is designed to be generic in content and may not include all requirements for your particular installation. |
| F622-039-000 |
Alteration Re-Roofing for Low Slope Roofing
Checklist used by the contractor when altering a low slope roof. |
| F622-040-000 |
Flood Damaged Manufactured Home Checklist
Checklist on how to repair a flood damaged manufactured home. After the contractor has done all that is required by the checklist they call L&I for an inspection. |
| F622-043-000 |
Is it a Manufactured / Mobile Home?
If your home has any of the items in this document, it is a manufactured / mobile home and requires inspections for all alterations by L&I's Factory Assembled Structures Section. |
| F622-044-000 |
Steel or Wrought-Iron Gas Line Pre-Inspection Checklist
This checklist is used by the contractor when installing steel or wrought-iron gas line. Be sure you can answer YES to all questions before calling L&I for an inspection. |
| F622-045-000 |
Gas Room Heaters Pre-Inspection Checklist
This checklist is used by the contractor when installing gas room heaters. Be sure you can answer YES to all questions before calling L&I for an inspection.
|
| F622-046-000 |
Copper Tubing Gas Line Pre-Inspection Checklist
This checklist is used by the contractor when installing gas lines with copper tubing. Be sure you can answer YES to all questions before calling L&I for an inspection.
|
| F622-048-000 |
Gas Piping Test Affidavit
You fill out, print and make a copy of this form on your company's letterhead. This affidavit must be available for the L&I inspector when the inspection is made. |
| F622-049-000 |
Your Manufactured / Mobile Home
Pamphlet/booklet: Covers things you should consider when altering your home. Defines what is meant by alteration, repair and replacement and includes tips for hiring a registered contractor. It also includes contact information for L&I Consumer Assistance Program for owners of new manufactured/mobile homes. |
| F622-049-999 |
Your Manufactured/Mobile Home-Spanish (Casas prefabricadas y móviles:
Lo que los dueños de casas y contratistas deben saber al modificar una vivienda)
Pamphlet/booklet: Covers things you should consider when altering your home. Defines what is meant by alteration, repair and replacement and includes tips for hiring a registered contractor. It also includes contact information for L&I Consumer Assistance Program for owners of new manufactured/mobile homes. |
| F622-053-000 |
Alteration Polybutylene Re-Pipe Pre-Inspection Checklist
This checklist is used by the contractor when altering a polybutylene re-pipe. Be sure you can answer YES to all questions before calling L&I for an inspection.
|
| F622-054-000 |
Homeowners Manufactured / Mobile Home Variance Request
This variance request applies only to the installations performed by a previous owner and does not apply to any home during the warranty period. |
| F622-063-000 |
Decertification of Manufactured and Mobile Homes
This document shows the steps to decertify a manufactured or mobile home. |
| F622-072-000 |
Vendor / Medical Conversion Units Pre-Inspection Checklist
Pre-Inspection Checklist to assist vendor owners, manufacturers, and others on what they need to know to get their vendor/medical unit approved by Labor and Industries. |
| F622-073-000 |
RCW 43.22.380 Exemptions Fire and Safety Checklist for Vendor/Medical Conversion Units
Generic Checklist to determine if the particular installation includes all requirements prior to calling for an inspection. Must be able to answer YES to all questions prior to calling. |
| F622-075-000 |
Structural Inspection Request Questionnaire
Structural Inspection Request Questionnaire |
| F622-076-000 |
Roof Affidavit
Roof Affidavit |
| F623-006-000 |
Plan Approval Request - Factory Built Structures and Commercial Coaches
A manufacturer of factory-built structures and/or commercial coaches uses this form to submit plans to L&I for review. |
| F623-013-000 |
Notification to Local Enforcement Agency
L&I sends this form to notify the local agencies when a modular/moblie home is being built within a county or city limits. |
| F623-014-000 |
Application for Insignia for Factory Built Structures
Manufacturer uses this form to apply for an official insignia for a manufactured / mobile home that has a plan approval number. |
| F623-016-000 |
Electrical Plan Approval Request - Factory Built Structures & Commercial Coaches
Used by the manufacturer to request approval from L&I on an eletrical plan to build manufactured / mobile home(s) or commercial coaches. |
| F623-017-000 |
Panel Load Calculations
Listing of Connected Loads and the Demand Loads. Used for all appliances that are fastened in place, permanently connected on specific circuit. Single Phase Panel Schedule and Three Phase Panel Scheule inlcude. Sample diagram included. |
| F623-019-000 |
Application for Insignia for Commercial Coaches
Manufacturer uses this form to apply for an official insignia for commercial coaches that have a plan approval number.
|
| F623-021-000 |
Application for Insignia Conversion Vendor/Medical Units
Used to apply for an official insignia for conversion vendor or medical unit factory-assembled structures. See sample form for instructions about how to fill out the form correctly. |
| F623-025-000 |
Factory Assembled Structure Alteration Permit Refund Request
A form to request a refund for a factory-assembled structure alteration permit. |
| F625-001-000 |
Application for Contractor Registration
This is the form you would complete to register as a general contractor or specialty contractor. This is not in the warehouse. Please print off of the internet. |
| F625-003-000 |
Continuous Contractor's Surety Bond
This form is used for the surety bond for construction contractors. |
| F625-008-000 |
Assignment of Account - WA State Banks Only
Contractors may use this form to request an Assignment of Account in lieu of a surety bond. The amount of the surety bond would need to be placed into an account at a WA State Bank. |
| F625-011-000 |
Reassignment of Savings Account or Time Deposit - Construction Contractors
Contractors may use this form to request changes to a Assignment of Savings that was filed in lieu of a surety bond or insurance policy. |
| F625-017-000 |
Facts About Construction Liens
Fact sheet: Explains the basics of the construction lien law to help consumers protect themselves. |
| F625-029-000 |
Release of Lien by Contractor and Subcontractor(s) - Sample only
This is a sample of a release of lien by a contractor or a subcontractor. |
| F625-030-000 |
Model Disclosure Statement Notice to Customer
This disclosure statement is given to the consumer (customer) from the contractor showing they are registered in the state of Washington. The consumer (customer) signs this form as acknowledgement of receipt. |
| F625-033-000 |
Contractor Complaint Form
Used by a home owner to file a complaint against a contractor. |
| F625-040-000 |
Construction Contractors: Get the Facts, Get Registered
Pamphlet/booklet: Explains the steps to register as a construction contractor in Washington State. |
| F625-040-999 |
Construction Contractors: Get the Facts, Get Registered - Spanish (Contratistas de Construcción:
Obtenga los datos, regístrese)
Pamphlet/booklet: Explains the steps to register as a construction contractor in Washington State. |
| F625-051-000 |
Subscription Request for Construction Contractor and Electrical Basic - CD
This form is to be used to purchase the CD ROM of registered construction contractors, registered electrical contractors, plumbers and electricians. |
| F625-053-000 |
Filing Suit Against an Electrical Contractor
Instructions for filing suit against an electrical contractor |
| F625-054-000 |
Construction Lien Notice
This form is to be used by suppliers to notify homeowners that they have the ability to file a construction lien against their property if payment is not received. |
| F625-055-000 |
Construction Lien Summary
General requirements that a lien claimant of a private construction project (not a commercial) must meet. This is intended show the general requirements for most lien claimants. |
| F625-061-000 |
Contractor Financial Information
Used by the contractor to request L&I to release assignment of account that they used instead of a surety bond. |
| F625-066-000 |
Affidavit to Release Public Records
This form is to request L&I to release public records in the contractors registration section. |
| F625-069-000 |
Registered Contractor Card
This is a fillable version of the Registered Contractot Card |
| F625-077-000 |
Construction Contractor's Application for Worker's Compensation Account with No Worker Hours
Used by employers with no employees or worker hours to report but need an open account for contract bidding process. |
| F625-082-000 |
Assignment of Account or Time Deposit for Insurance - Bodily Injury - WA State Banks Only
Contractors may use this form to request an Assignment of Account in lieu of an insurance policy for bodily injury. The amount of the insurance policy would need to be placed into an account at a WA State Bank.
|
| F625-083-000 |
Assignment of Account or Time Deposit for Insurance - Property Damage - WA State Banks Only
Contractors may use this form to request an Assignment of Account in lieu of an insurance policy for property damage. The amount of the insurance policy would need to be placed into an account at a WA State Bank. |
| F625-084-000 |
Hiring a Contractor or Remodeler? What You Should Know
Pamphlet/booklet: Provides a checklist for consumers considering hiring a general or specialty construction contractor, reviews the permitting process, and suggests ways to avoid lien problems. Washington State law requires contractors to register with L&I. |
| F625-084-999 |
Hiring a Contractor or Remodeler? What You Should Know-Spanish (¿Piensa contratar a un contratista de construcción o remodelador?)
Fact sheet: Provides a checklist for consumers considering hiring a general or specialty construction contractor, reviews the permitting process, and suggests ways to avoid lien problems. Washington State law requires construction contractors to register with L&I. |
| F625-088-000 |
What to Do if You Want to File Suit Against Your Construction Contractor
Fact sheet: Provides consumers with general information about the process for filing suit, and describes L&I's limited role in serving Summons & Complaint papers. |
| F625-094-000 |
Request for Archive Records - Contractor Registration
This form is to request L&I to release archive records in the contractors registration section. |
| F625-097-000 |
Contractors: What if You Get a Notice of Infraction?
Pamphlet/booklet: Tells contractors what their options are and what to do if they get a Notice of Infraction (a non-criminal violation). |
| F625-098-000 |
Washington Contractor's License Bond Validation Rider
This rider is intended to be used in conjunction with a bond. |
| F625-099-000 |
Washington Contractor's License Bond Name Change Rider
Used by the bond company to change the name of the contractor's business. |
| F625-100-000 |
Washington Contractor's License Bond License Number Change Rider
Used by the bond company to change the contractor's business license number. |
| F625-101-000 |
Washington Contractor's License Bond Date Change Rider
Used by the bond company to change the effective date of the contractor's bond. |
| F625-102-000 |
Washington Contractor's License Bond Bond Amount Rider
Used by the bond company to amend the amount of the contractor's bond. |
| F625-103-000 |
Washington Contractor's License Bond Entity Change Rider
Used by the bond company to show a change in the business structure of a contractor's business. |
| F625-104-000 |
Washington Contractor's License Bond Address Change Rider
Used by the bond company to change the address of the contractor's business. |
| F625-107-000 |
Renewal Application for Contractor Registration
Renewal Application for Contractor Registration |
| F625-108-000 |
Contractor Registration Request for Duplicate License or Address Change
Contractor Registration Request for Duplicate License or Address Change |
| F625-109-000 |
Contractor Regsitration Officers/members Addendum
Contractor Regsitration Officers/members Addendum |
| F626-001-000 |
Application for Electrician Examination
Application and instructions for a Washington State electrician's certificate examination. |
| F626-048-000 |
Application / Renewal for an Electrical Training Certificate
This the application for an Electrical Training Certificate or the renewal of. (This does NOT make you a registered apprentice). |
| F627-003-000 |
Application for Plumber Trainee Certificate
This form is used to apply for a plumber trainee certificate. |
| F627-004-000 |
Affidavit of Experience - Plumbers
This form is required to report plumber trainee's plumbing experience for credit towards journeyman or specialty status. |
| F627-008-000 |
Application for a Journeyman, Residential Specialty, Rec Plumbers or Med Gas Certificate
This form is used to apply for plumber examination, reciprocal and medical gas endorsement. |
| F627-014-000 |
Request for Duplicate Certificate
This form is used to request a replacement certificate for a plumber or plumber trainee. |
| F627-019-000 |
Journeyman, Specialty, Medical Gas Installer or Trainee Renewal
This form is used to renew a plumber certification, plumber trainee or medical gas installer certification. |
| F627-022-000 |
Facts about State Certification for Plumbers
Fact sheet: Explains plumber classifications, certification requirements, including required exams, and the application and renewal processes, including continuing education requirements. |
| F627-026-000 |
Facts about Medical Gas Piping Installer Endorsement
Fact sheet: Explains training requirements and the endorsement process for medical gas piping installers. |
| F627-027-000 |
2009 and 2010 Plumbers Examination Dates and Locations
This shows the current plumber examination dates and locations for the year 2009 and 2010. There are two separate files - the top file is the 2009 dates and the bottom file is the 2010 dates. The 2010 dates are not printed for the L&I warehouse yet. Please print a copy off of the internet. |
| F627-033-000 |
Application for Backflow Trainee Certificate
This form is used to apply for a backflow trainee certificate. |
| F627-035-000 |
Application for Backflow Specialty Exam
This form is used to apply for the backflow specialty examination. |
| F627-037-000 |
Plumber Continuing Education Course Application
This form is used by the course sponser to submit continuing education courses for plumber certification. |
| F627-039-000 |
Plumber Request for Change of Address
Plumber Request for Change of Address |
| F627-043-000 |
Affidavit of Continuity
Affidavit of Continuity |
| F700-002-000 |
Parent / School Authorization for Employment of a Minor and Special Variance
For legal guardians and school officials to approve a minor employee to work according to terms listed by the employer. This is NOT a work permit. Employers must obtain a minor work permit endorsement on their Master Business License where they employ workers under 18. The Special Variance for 16- and 17-year-olds to work up to 28 hours during the school weeks, is on page two of Parent/School Authorization form.
|
| F700-007-000 |
Affidavit of Wages Paid - Public Works Contract - SAMPLE ONLY
Sample copy with instructions: Used by a contractor, company or agency to show the wages paid to employees. This needs to be filed at the completion of a public works job/project. This PDF file will not print. Copies are available in the warehouse, 25 per pad. |
| F700-009-000 |
Record Keeping Provisions - Employment Standards
This form is for employers to use to keep records on every employee. |
| F700-010-000 |
Operating Power Lawn and Yard-care Equipment: Safety for Teen Workers
Fact sheet: Overview of safety practices, plus information on what equipment employees under 18 can and cannot operate. Provides resources on requirements for hearing protection and PPE (personal protective equipment). |
| F700-014-000 |
Application for Farm Labor Contractor License
Used to apply or renew a license. |
| F700-022-000 |
Teens at Work: Facts for Employers, Parents and Teens
Pamphlet/booklet: Answers questions employers, parents and teens may have about employing teen workers (ages 14-17). Explains non-agriculture work rules, including the necessary permits, hours and work conditions. Provides links to other resources. |
| F700-022-999 |
Adolescentes en el Trabajo: Los hechos para los empleadores, los padres y los adolescentes
Pamphlet/booklet: Answers questions employers, parents and teens may have about employing teen workers (ages 14-17). Explains non-agriculture work rules, including the necessary permits, hours and work conditions. Provides links to other resources. |
| F700-024-000 |
Wage Transcription and Computation Sheet
Employer uses this to show time worked and wages earned for an employee. |
| F700-027-999 |
Prevailing Wage Complaint and Instructions - Spanish - Instrucciones Para El Registro
De Una Queja Sobre Los Derechos Laborales
The Prevailing Wage form is now F700-146-000. This form is the Spanish version of the old Prevailing wage form. This will be replaced by F700-146-999 when the Spanish translation is completed. Ask L&I to conduct an investigation into a prevailing wage-related that affects one or more employees. See box 30 on the form to see what types of complaints are covered. |
| F700-029-000 |
Statement of Intent to Pay Prevailing Wages Public Works Contract SAMPLE ONLY
Sample copy of the form that Contractors and Sub-contractors file a Statement of Intent to Pay Prevailing Wages public works contract upon accepting work on a public works project. This PDF file will not print. Copies are in the warehouse, order by the pad (25 a pad). |
| F700-032-000 |
Washington State Prevailing Wage Law
Booklet: Contains the prevailing wage laws (RCWs) and rules (WACs) as well as plain language descriptions and contact information. |
| F700-041-000 |
Minimum Wage Law Booklet
Covers Washington State Minimum Wage Law. |
| F700-046-000 |
Agreement - Farm Labor Contractors and Workers
Employment wages and conditions agreement with Farm Labor Contractors and Workers |
| F700-046-999 |
Agreement - Farm Labor Contractors and Workers - Spanish - Acuerdo Entre Contratistas Agrícolas Y Trabajadores
Employment wages and conditions agreement with Farm Labor Contractors and Workers |
| F700-051-000 |
Minimum Wage Law Exemptions
Covers exemptions to Washington state minimum wage law. |
| F700-058-000 |
Employer Rights - Wages Paid
Covers penalties for employer wage violations. Once stock runs out in warehouse, this form will be internet only. |
| F700-060-000 |
Farm Labor Contractor Assignment of Account or Time Deposit
Farm Labor Contractor assignment of account or tme deposit for employee |
| F700-061-000 |
Farm Labor Contracting Rules
Covers Farm Labor Contracting Rules for licensing and revocation, violations and legal procedures, and penalties. |
| F700-064-000 |
Payment of Wages - RCW 49.48.010 and 49.52.050
This is a copy of the law that pretains to the payment of wages to an employee when they stop working for an employer. The wages due to the employee for the pay period worked prior to leaving. |
| F700-065-000 |
Certified Project Payroll
There are instructions in one PDF file, and a blank form that may be printed in the other PDF. The word document is saved in Microsoft 2003 format and is a fillable word form. |
| F700-066-000 |
Farm Labor Contractors Bond
Notarized farm labor contractors bond coverage. |
| F700-067-909 |
Contracted Farm Workers Rights (English/Spanish)
Covers workers rights when working for a farm labor contractor. |
| F700-074-909 |
Your Rights as a Worker in Washington State (English/Spanish) / Sus derechos como trabajador en el estado de Washington
Required poster: Reviews workers' rights under Washington's wage-and-hour laws. Topics include minimum wage, overtime, meal and rest breaks, pay periods, deductions, and employment of teens under age 18. Also reviews family leave provisions under federal and state law, and leave for spouses of deploying military personnel and victims of domestic violence. Note: Employers in both agricultural and non-agricultural industries in Washington State must display this poster where workers can see it. Get poster printing tips.
|
| F700-076-000 |
Variance Application - For exceptions from specific rules governing employment of minors.
Employer uses this application for requesting a variance to employment regulations for minors. |
| F700-079-000 |
Washington State OverTime Law
Covers compensation for employees in Washington State working overime. |
| F700-085-000 |
Chapter 296-131 WAC Agriculture Employment Standard
|
| F700-085-999 |
Agricultural Employment Standards - Chapter 296-131 WAC Spanish ESTÁNDARES DE TRABAJO AGRÍCOLA
Agricultural Employment Standards - Chapter 296-131 WAC Spanish ESTÁNDARES DE TRABAJO AGRÍCOLA |
| F700-088-000 |
Farm Labor Contractor Registration Fact Sheet
What Farm Labor Contractors need to know to Register for a License. |
| F700-089-000 |
Variance Application - Employment Standards
Employer application request for a variance from employment standards for non minor employees. |
| F700-095-000 |
Minimum Wage Law - Truck Drivers
Record keeping provisions and overtime for truck & bus drivers. |
| F700-096-909 |
Young Workers in Agriculture (English/Spanish) - Trabajadores jóvenes en la agricultura
Pamphlet/booklet: Answers many questions employers and minor workers have about employing minors. Covers agriculture work rules, including the necessary permits, hours and work conditions for workers 12-17 years of age. |
| F700-097-000 |
Washington State Deduction Laws
Deductions for current & terminated employees and employer liability for paying less than required. |
| F700-098-000 |
Internal Revenue Service Tax Compliance Certification
Form to gain Internal Revenue Service Tax Compliance Certification for registered Farm Labor Contractors. Now includes IRS form 8821 Tax Information Authorization. |
| F700-099-000 |
Department of Employment Security Tax Compliance Certification
Form to gain Department of Employment Security Tax Compliance Certification for registered Farm Labor Contractors. |
| F700-100-000 |
Department of Revenue Tax Compliance Certification
Form to gain Department of Revenue Tax Compliance Certification for registered Farm Labor Contractors. |
| F700-102-909 |
Washington Minimum Wage Poster (English and Spanish) - Cartel del Salario Mínimo de Washington
Poster: Lists the minimum wage and basic facts about minimum wage. Get poster printing tips. |
| F700-103-909 |
Agricultural workers information line (English/Spanish)
Card: Wallet card with a toll-free telephone number where agricultural workers can call to learn about their workplace rights. |
| F700-105-909 |
Your Daily Record of Hours Worked (English/Spanish) / Su Registro de Horas Trabajadas
Pamphlet/booklet: A pocket-sized bilingual booklet to encourage agricultural workers to keep track of their daily work hours and earnings. |
| F700-109-000 |
Farm Labor Contractor Complaint Form
Used to file a complaint against a Farm Labor Contractor, landowner, employer, or other where a possible infraction is concerned. |
| F700-109-999 |
Formulario De Queja En Contra De Un Contratista De Trabajores Agricolas (Farm Labor Contractor Complaint)
Used to file a complaint against a Farm Labor Contractor, landowner, employer, or other where a possible infraction is concerned. |
| F700-112-000 |
Farm Labor Contractor Checklist
Farm Labor Contractor's Checklist to ensure compliance. |
| F700-112-999 |
Lista De Comprobacion Para Un Contratista De Trabajores Agricolas (Farm Labor Contactor Checklist)
Farm Labor Contractor's Checklist to ensure compliance. |
| F700-115-000 |
Are You an Employer or a Parent of a Teen Worker?
Fact sheet: Presents facts and resources to help employers and parents keep teen workers safe on the job. |
| F700-115-999 |
¿Es Ud. un empleador o padre de un trabajador adolescente?
Fact sheet: Presents facts and resources to help employers and parents keep teen workers safe on the job. |
| F700-117-000 |
Employing Minors Under Age 14 in Non-Agricultural Jobs
Fact sheet: Explains when employers can and cannot employ minors under age 14 in non-agricultural jobs. Details the process for obtaining court permission when hiring minors under 14 is allowed. |
| F700-118-000 |
Employer Petition to The Court for Minor Work Permit Under Age 14
Petition to The Court for Minor Work Permit Under Age 14 by Employer. |
| F700-119-000 |
Court Form Granting Permission for Employment of Minors
Form from Court Granting Permission for Employment of Minors to the employer. |
| F700-120-000 |
Application for Special Certificate to Employ at A Subminimum Wage Rate
Employer Application for Special Certificate to Employ at A Subminimum Wage Rate. |
| F700-121-000 |
Application for House to House Sales Sales Employer Registration Certificiate
Used by employers to register as employing minors who will be engaged in house-to-house sales, as required by WAC 296-125-120, with Labor and Industries. |
| F700-122-000 |
Application for Special Certificate to Employ A Vocationally Handicapped Worker at at Subprevailing Wage Rate
Employer Application for Special Certificate to Employ A Vocationally Handicapped Worker at at Subprevailing |
| F700-124-000 |
Summary of Agricultural Employment Regulations and Farm Contractor Requirements
This summary is on employment laws relating to the agricultural industry. |
| F700-125-000 |
Agricultural Employer Worksheet
Used by agricultural employers to assist them in determining if they are following the state Agricultural Employment Standards and the Minimum Wage Act for their employees. |
| F700-126-000 |
L&I Agricultural Website and Telephone Resources
This lists information about the agricultural information that can be found on the L&I website. It also has phone numbers to pertinent information. |
| F700-127-000 |
Farm Labor Employer Packet
Packet of information for Farm Labor Employers. Packet has updated F700-124-000 form dated 6-2007. Packet includes other forms and RCW and WAC references. |
| F700-129-000 |
Interested Party Checklist for the Filing of Prevailing Wage Complaints
Checklist used for the filing of Prevailing Wage Complaints by "Interested parties" ONLY. |
| F700-130-000 |
Sports Teams and Youth Workers
Fact sheet: Explains the requirements for sports organizations that engage young people as volunteers or employees to referee, assist or work for the organizations. The focus is workers' compensation coverage and minor work rules. |
| F700-135-000 |
Seasonal Group Variance Application
Used for Exceptions from the Hours of Work for Minors for Seasonal work. This form is a word document and can be completed electronically. If you have an electronic signature, you may use it on the form. You may save the form and send it as an attachment via email to the address at the top of the form, i.e., teensafety@Lni.wa.gov. If you do not have an electronic signature, complete the form, save it in your files, print it, sign it and fax or mail it to the address at the top of the form.
Variance Application forms may be faxed to (360) 902-5300. If you would like the approved Variance Certificate faxed back to your business, please state so on your cover sheet.
|
| F700-139-000 |
Safety Steps for Supervisors and Employees in Restaurants
Fact Sheet: A useful summary of the responsibilities both employers and employees share for a safe workplace. This can be shared with new employees during their initial orientation. |
| F700-140-000 |
Restaurant Employee Safety Orientation Checklist
Fact Sheet: Download this checklist to help with the safety orientation of new restaurant employees. |
| F700-141-000 |
Request for Public Records Prevailing Wage - Certified Payroll RCW 42.56
Used to request copies of Certified Payrolls for prevailing wage projects. |
| F700-142-000 |
Hiring Teens this Summer?
Flier: Provides important information about hiring teens, including extra safety precautions, as well as legal requirements regarding minor work endorsement, hours and prohibited duties. Provides telephone, e-mail and Web contacts for more information. |
| F700-142-999 |
Hiring Teens this Summer?-Spanish (¿Piensa contratar adolescentes este verano?)
Flier: Provides important information about hiring teens, including extra safety precautions, as well as legal requirements begarding minor work endorsement, hours and prohibited duties. Provides telephone, e-mail and Web contacts for more information. |
| F700-143-000 |
Affidavit of Wages Paid Addendum B List of Next Tier Subcontractors - Public Works Contract
Copies of the 05-2008 version will be available in the warehouse later in July. |
| F700-144-000 |
Protected Leave Complaint
For leave from work complaints: Download and complete a Protected Leave Complaint form (F700-144-000) |
| F700-145-909 |
Youth in Construction - English/Spanish (Adolescentes en construcción)
Booklet/pamphlet: Explains the limits on work teens under age 18 can perform in the construction industry, discusses the importance of training and emphasizes safety. Includes a checklist of "do's" and "don'ts" for employers, plus other resources. |
| F700-146-000 |
Prevailing Wage Complaint and Instructions
Ask L&I to conduct an investigation into a prevailing wage violation that affects one or more employees. See box 30 on the form to see what types of complaints are covered. This form used to be F700-027-000. The Spanish version F700-027-999 is still on the internet until this form is translated into Spanish. IMPORTANT The Worker Rights Complaint form is now F700-148-000 |
| F700-147-000 |
Farm Labor Contractor Certified Payroll
Farm Labor Contractor Certified Payroll |
| F700-148-000 |
Worker Rights Complaint Form
This is the NEW Worker Rights Complaint Form. IMPORTANT: The Prevailing Wage Complaint form is now F700-146-000. |
| F700-148-999 |
Worker Rights Complaint Form - Spanish formulario de queja sobre los derechos laborales
Worker Rights Complaint Form - Spanish formulario de queja sobre los derechos laborales. This form will be available in the warehouse the second week of October. Please print from the internet before that date. |
| F700-152-999 |
Plain Talk Summary of Prevailing Wage Laws: Understand Your Responsibilities and Rights When Performing Public Work (Resumen de las leyes de salario prevaleciente en lenguaje sencillo
Entienda sus responsabilidades y derechos al hacer trabajos públicos)
8.5" X 11" sheets: Provides a summary of prevailing wage laws and rules in Spanish. This publication is only available in Spanish. For similar information in English, read Washington State Prevailing Wage Law (F700-032-000). |
| F800-006-909 |
Help for Crime Victims (English/Spanish) - Ayuda para Victimas de Crimen
Pamphlet/booklet: Answers questions about Washington State's Crime Victims Compensation Program, who may be eligible for benefits and how to apply. |
| F800-025-000 |
Statement for Crime Victims Mental Health Services
Used by the Crime Victims Compensation Program providers for reimbursement of Mental Health Services. |
| F800-031-000 |
Application to Reopen Crime Victim Claim for Aggravation of Condition
Used by victims of crime and medical or mental health providers to request a claim be reopened. 2-08 version is on the internet, 8-95 version is in the warehouse. |
| F800-031-999 |
Application to Reopen Claim - Spanish Aplicación Para Reabrir Un Reclamo Debido Al Empeoramiento De La Condición
Used by victims of crime and medical or mental health providers to request a claim be reopened. 2-08 version is on the internet, 8-95 version is in the warehouse. |
| F800-041-000 |
Help for Crime Victims (large poster)
Poster: Provides contact information for the Crime Victims Compensation Program. Intended for display in health-care, criminal-justice and social-service organizations that assist crime victims. The size is 11" X 17" if ordered from the Crime Victims Compensation Program. If you print from the Web, the poster will be 8.5" X 11".
|
| F800-041-999 |
Help for Crime Victims (large poster) - Spanish (Ayuda para Victimas de Crimen)
Poster: Provides contact information for the Crime Victims Compensation Program. Intended for display in health-care, criminal-justice and social-service organizations that assist crime victims. The size is 11" X 17" if ordered from the Crime Victims Compensation Program. If you print from the Web, the poster will be 8.5" X 11". |
| F800-042-000 |
Application for Benefits - Crime Victims
Used by victims of a crime in Washington State to receive benefits for time lost from work, loss of financial support, medical or mental health treatment. |
| F800-042-999 |
Instrucciones para la aplicación de beneficios - Instructions in Spanish for completing the Application for Crime Victims Benefits in English
Instructions in Spanish to complete the English form F800-042-000 Application for Crime Victim benefits. The form is used by victims of a crime in Washington State to receive benefits for time lost from work, loss of financial support, medical or mental health treatment. |
| F800-049-000 |
Travel Reimbursement Request - Crime Victims
If you are considered a victim of crime, use this form to track your travel expenses for medical, retraining or vocational services or for an independent medical exam. You should have approval from your claim manager before you travel. |
| F800-053-000 |
Master Level Counselor Provider Account Application for Crime Victims
Master Level Counselor Provider Account Application for Crime Victims |
| F800-057-909 |
Request for Survivor Counseling Benefits (English/Spanish)
Used by immediate family members of homicide victims to request mental health counseling. |
| F800-058-000 |
Statement for Pharmacy Services - Crime Victims
Used by Crime Victims Compensation Program providers to bill for pharmacy services. Crime Victims Compensation Program providers are required to bill using this form. |
| F800-064-000 |
Provider's Request for Adjustment - Crime Victims
Used by providers to request an adjustment to their bill if their entire bill was paid in error, or if a portion of the bill was overpaid or underpaid. Attach required reports and/or documentation to support the request. |
| F800-065-000 |
Request for Taxpayer Identification Number and Certification - Form W-9
Used by a provider assisting victims of crime to obtain a taxpayer ID number. |
| F800-070-000 |
Statement for Home Nursing Services - Crime Victims
Used by the Crime Victims Compensation Program providers for reimbursement of home nursing services. Crime Victims Compensation Program providers are required to bill using this form. |
| F800-074-000 |
Know What to Expect: How Recoveries and Settlements May Impact Your Crime Victim Claim
Pamphlet and form: Explains third-party liability, recoveries and settlements. A crime victim or the Crime Victims Compensation Program may pursue monetary restitution from someone who caused or contributed to a crime victim's injury. Explains the purpose of the form and why individuals who file a crime victims claim are required to complete it. |
| F800-076-000 |
Statement for Crime Victim Miscellaneous Services
Used by the provider or supplier for reimbursement of the following services - dental, glasses, home health, nursing home serivces, medical equipment, prosthetics-orthotics, transportation, vocational, retraining and other. |
| F800-080-000 |
Crime Victims Compensation Program Initial Response and Assessment: Form I
Used by the clinical provider to get approval to see a victim for six sessions or less. If more than six sessions, please complete Form II (F800-081-000). |
| F800-081-000 |
Crime Victims Compensation Program Initial Response and Assessment: Form II
Used by the clinical provider to request authorization to provide more than six sessions. This form must be submitted by the sixth session. (6 pages) |
| F800-082-000 |
Crime Victims Compensation Program Progress Note: Form III
Used by the clinical provider to submit a request for preauthorization for payment of additional sessions. |
| F800-083-000 |
Crime Victims Compensation Program Treatment Report: Form IV
Used by the clinical provider to request preauthorization for payment of additional sessions. |
| F800-084-000 |
Crime Victims Compensation Program Treatment Report: Form V
Used by the clinical provider to get preauthorization for payment of additional sessions. |
| F800-085-000 |
Crime Victims Compensation Program Termination Report: Form VI
Used by the clinical provider to inform L&I that you are no longer conducting treatment to the client. This must be submitted within 60 days of the client's last session and you are no longer conducting treatment. |
| F800-089-000 |
Provider Accounts Change Form for Crime Victims Compensation
Providers use to inform L&I that they have changes to their account. Such as changes to their Tax ID address/name, business address, billing address, name, or termination of account. This also includes a W-9 form. |
| F800-095-000 |
Crime Victim's Compensation Claim for Pension by Dependents
Used by dependents of a deceased Crime Victim to determine eligibility to receive pension benefits. |
| F800-095-999 |
Crime Victims Request for Pension by Dependents - Spanish
Used by Spanish speaking dependents of deceased crime victims who are applying for pension benefits. |
| F800-098-000 |
Crime Victim Compensation Program Sexual Assault Exam Report
A form used by physicians, hospitals and clinics to provide information and reporting to the Crime Victims Compensation Program. |
| F800-100-000 |
Billing Guidelines for Sexual Assault Examinations: Crime Victims Compensation Program
Provides information health-care providers need to bill the Crime Victims Compensation Program for medical services. |
| F800-102-000 |
Helping Providers Understand the Crime Victims Compensation Program
Fact sheet: Answers questions doctors and mental health counselors may have about the Crime Victims Compensation Program and billing for services. Also suggests steps these providers can take to speed up reimbursement. |
| F800-104-000 |
Help for Crime Victims (small poster)
Poster: Provides contact information for the Crime Victims Compensation Program. Intended for display in health-care, criminal-justice and social-service organizations that assist crime victims. This poster is 8.5" X 11." |
| F800-104-999 |
Help for Crime Victims (small poster) - Spanish (Ayuda para Victimas de Crimen)
Poster: Provides contact information for the Crime Victims Compensation Program. Intended for display in health-care, criminal-justice and social-service organizations that assist crime victims. This poster is 8.5" X 11." |
| F800-105-000 |
Mental Health Fee Schedule and Billing Guidelines
Manual: This manual is for providers who bill the Crime Victims Compensation Program for mental health services for crime victims. |
| F800-107-000 |
Crime Victims Insurer Activity Prescription Form (APF)
Crime Victims Insurer Activity Prescription Form (APF) |
| F800-110-000 |
Victim Verification Form
For use by crime victims requesting time-loss compensation |
| F800-110-999 |
Crime Victim Worker Verification - Spanish FORMULARIO DE VERIFICACIÓN DE EMPLEO
Crime Victim Worker Verification - Spanish FORMULARIO DE VERIFICACIÓN DE EMPLEO |
| F800-111-999 |
Crime Victim Pension Benefits Questionnaire Form for Crime Victims - CUESTIONARIO PARA BENEFICIOS
DE PENSIÓN
Crime Victim Pension Benefits Questionnaire Form for Crime Victims - CUESTIONARIO PARA BENEFICIOS |
| F800-112-000 |
Crime Victims Address Change Request
Crime Victims Address Change Request |
| FSP0-900-001 |
Sticker - Emergency Information
|
| FSP0-901-000 |
Safety Comes Thru Job Training
A supervisor having a discussion with his crew. Get poster printing tips. |
| FSP0-903-000 |
Ten Safe Handling Hints for Knives
Shows ten tips on handling a knife safely. Get poster printing tips. |
| FSP0-904-000 |
Preventing Slips and Falls
Information on how to prevent slips and falls with your footwear, housekeeping and also some general awareness tips. Get poster printing tips. |
| FSP0-905-000 |
Fryer Safety
Tips on deep frying safety. Get poster printing tips. |
| FSP0-906-000 |
Ten Steps for Avoiding Burns
Tips on how to avoid burns while cooking. Get poster printing tips. |
| FSP0-907-000 |
Does This Ring a Bell? Wear Your Hard Hat
Picture of a guy getting hit in the head with a large metal hook. Get poster printing tips. |
| FSP0-908-000 |
Stay Clear of Suspended Loads
Pictures a guy under a suspended wooden carton. Get poster printing tips. |
| FSP0-912-000 |
No Shoring Can be a Grave Situation
Picture of a front loader above and it's bucket scooping up dirt in a large hole with a worker also in the hole. Get poster printing tips. |
| FSP0-915-000 |
The Best Accident Insurance - To observe all safety regulations
Picture of a guy with Saftey Policy and Rules in his hand. Get poster printing tips. |
| FSP0-918-000 |
Four Steps to Proper Lifting
Pictures of a person lifting a large box correctly along with tips on how to correctly lift a large item safely. Get poster printing tips. |
| FSP0-919-000 |
Robberies and Abusive Customers: Tips for Preventing Injuries
Tips on handling cash and how to have a safer restaurant or retail environment. Get poster printing tips. |
| FSP0-928-000 |
Caution: Hard Hat Area
Visual reminder of the importance of wearing a hard hat. Get poster printing tips. |
| FSP0-928-999 |
Precaución: Obligatorio Usar Casco
Picture of hard hats. Get poster printing tips. |
| FSP0-940-000 |
Always Wear Eye Protection
Picture of a large eye with some content on when to use eye protection. Get poster printing tips. |
| FSP0-940-999 |
Siempre Use Protección para los ojos
Picture of a large eye with some content on when to use eye protection. Get poster printing tips. |
| FSP0-941-000 |
Always Wear Eye Protection
Sticker: 7.25 inches X 4.25 inches. |
| FSP0-951-000 |
Ladder Safety
Picture of a ladder with safety tips on the rungs. Get poster printing tips. |
| FSP0-954-000 |
Keys to Safety
Picture of two keys with the words 'Skills' and Knowledge' on them. Get poster printing tips. |
| FSP0-963-000 |
Getting Killed is Easy
Large words that say: Getting killed is easy. Staying alive is work. Get poster printing tips. |
| FSP0-963-999 |
Matarse es Fácil. Mantenerse vivo es trabajo.
Large words that say: Getting killed is easy. Staying alive is work. |
| FSP0-972-000 |
Danger! Minimum Clearance for Counter Balance - Logging
|
| FSP0-974-000 |
Danger! Minimum Clearance for Counter Balance - Construction
Sticker: 30 inches long. |
| FSP0-978-000 |
Safe Ways - Fork Lift Safety
Safety tips on using a fork lift. Get poster printing tips. |
| FSP0-993-000 |
Put this Guard Back
Sticker: 8.5 inches X 3.5 inches |
| FSP0-993-001 |
Put this Guard Back
Sticker: 5 1/2 inches X 2 1/8 inches |
| FSP0-993-991 |
Put this Guard Back (Spanish)
Sticker: 5.5 inches X 2.15 inches |
| FSP0-993-999 |
Put this Guard Back (Spanish)
Sticker: 8.5 inches X 3.5 inches |
| FSP1-000-000 |
Grinding Wheel - Prevent Accidents
Sticker: No size available |
| FSP1-004-000 |
Report All Injuries Promptly
Large words: Report All Injuries Promptly. Get poster printing tips. |
| FSP1-004-999 |
Reporte Todas Las Lesiones Inmediatamente
Large words: Report All Injuries Promptly. Get poster printing tips.
|
| FSP1-005-000 |
First Aid
Sticker: No size available |
| FSP1-010-000 |
Well...My Daddy Wears 'Em
Little boy wearing his daddy's hard hat, eye protection, gloves and boots. Get poster printing tips. |
| FSP1-012-000 |
Danger, Workers Above
Picture of workers on a high rise. Get poster printing tips. |
| FSP1-012-999 |
Danger, Workers Above-Spanish (Peligro, Trabajadores en el nivel superior)
Picture of workers on a high rise. Get poster printing tips.
|
| FSP1-013-000 |
Danger, Construction Area Authorized Personnel Only
Large words: Danger, Construction Area Authorized Personnel Only. Get poster printing tips. |
| FSP1-013-999 |
Peligro Área en Construcción Solamente Personas Authorizadas
Large words: Peligro Área en Construcción Solamente Personas Authorizadas. Get poster printing tips. |
| FSP1-030-000 |
Danger
Large lettering: DANGER. Get poster printing tips. |
| FSP1-030-999 |
Peligro
Large lettering: PELIGRO |
| FSP1-051-000 |
Walk, Don't Run
Timeless reminder to walk, don't run, showing a banana peel. Get poster printing tips. |
| FSP1-055-000 |
Watch Where You Step
Large lettering: Watch Where You Step. Get poster printing tips. |
| FSP1-063-000 |
Know Your Lockout Tagout Safety Procedure
Cartoon of a guy carrying a large lock and key with the words 'Know Your Lockout Tagout Safety Procedures'. Get poster printing tips. |
| FSP1-065-000 |
High Noise Area, Wear Hearing Protection
Cartoon of a guy plugging his ears with his fingers while his hearing protection is wrapped around his neck with the words 'High Noise Area' above his head. Get poster printing tips. |
| FSP1-075-000 |
Use Your Safety Equipment
Man working on a roof with fall protection, eye protection, work boots and the ladder is tied off. With words: Just Making Sure I Get Home Safely! Get poster printing tips. |
| FSP1-075-999 |
Use su equipo de protección (Spanish) - Use Your Safety Equipment
Man working on a roof with fall protection, eye protection, work boots and the ladder is tied off. With words: Just Making Sure I Get Home Safely! Get poster printing tips. |
|
|
