Fact sheet: Presents facts and resources to help employers and parents keep teen workers safe on the job.

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.

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.

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.

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.

Pamphlet/booklet: Provides a financial summary of Washington State's workers' compensation system, July 1, 2003 through June 30, 2004.

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.

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.

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.

Pamphlet: Provides a financial summary of Washington State's workers' compensation system, July 1, 2005, through June 30, 2006.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

This form is used to analyze accident prevention programs for your business. This is only available online.

Used to deposit money into your L&I account (Electrical).

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.

This form must be signed by the worker and the VRC and sent in along with the retraining plan to L&I for approval.

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.

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.

To renew your electrical certificate. Fee varies depending on renewal type.

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.

Affidavit of experience to apply for cetification as a Amusement Ride Inspector.

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.

Affidavit of Continuity

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.

This form is required to report plumber trainee's plumbing experience for credit towards journeyman or specialty status.

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.

Copies of the 05-2008 version will be available in the warehouse later in July.

This form is to request L&I to release public records in the contractors registration section.

Used by non-L&I agencies and jurisdictional authorities to request an inspection on an electrical harzard.

Employment wages and conditions agreement with Farm Labor Contractors and Workers

Employment wages and conditions agreement with Farm Labor Contractors and Workers

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.

Used by an employer to apply for self-insurance.

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.

Agricultural Employment Standards - Chapter 296-131 WAC Spanish ESTÁNDARES DE TRABAJO AGRÍCOLA

Card: Wallet card with a toll-free telephone number where agricultural workers can call to learn about their workplace rights.

This checklist is designed to be generic in content and may not include all requirements for your particular installation.

Employees use this form to report work place conditions which jeopardize workers safety and health.

Checklist for homeowners on how to upgrade their pre-HUD homes to approach the HUD standards in the area of fire safety.

Checklist for homeowners on how to upgrade their pre-HUD homes to approach the HUD standards in the area of fire safety.

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.

Checklist used by the contractor when altering a low slope roof.

Sticker: 7.25 inches X 4.25 inches.

Picture of a large eye with some content on when to use eye protection. Get poster printing tips.

Used by a self-insured employer to change items on the surety document such as amount of letter of credit issued as collateral.

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.

Used by self-insured employers to assist in fulfilling surety requirements.

This form is for an applicant to complete for Maritime or Construction Accreditation.

This the application for an Electrical Training Certificate or the renewal of. (This does NOT make you a registered apprentice).

Required if 3A, 6B, 7A, 7B, 7C, 7D, 7E, or 10 and have not completed the modified training requirements to receive specialty electrician cerfitication.

This form is used to apply for plumber examination, reciprocal and medical gas endorsement.

Used by an Engineer to apply for accreditation by L&I to approve unlisted equipment.

Application to be certified as an amusement ride inspector.

To apply for a decal for an amusement ride or air supported structure.

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.

Contractors use this form to apply to be a certified asbestos contractor in Washington state.

This form is used to apply for the backflow specialty examination.

This form is used to apply for a backflow trainee certificate.

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.

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.

Use this form to apply for an operators license of a charter vessel.

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.

Used by an employee to apply for copies of citation and notices issued to their employer.

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.

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.

Application used to get an electrical contractors license

Application and instructions for a Washington State electrician's certificate examination.

To exclude or include coverage for a family farm's children.

Used to apply or renew a license.

Used by organizations that want to form a retrospective rating group, or by established groups to modify their retro plan or maximum premium ratio.

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.

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.

Used by attorneys to be included on the Workers' Compensation Special Assistant Attorney General Program eligible list for Third Party claims.

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.

Manufacturer uses this form to apply for an official insignia for commercial coaches that have a plan approval number.

Manufacturer uses this form to apply for an official insignia for a manufactured / mobile home that has a plan approval number.

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.

Use this form to apply for the master electrician exam.

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.

Used by a spouse or children to apply for pension survivor benefits if a total permanent disabled worker dies.

Used by a spouse or children to apply for pension survivor benefits if a total permanent disabled worker dies.

This form is used by the logging industry to apply for a permit to operate a radio signal system.

This form is used to apply for a plumber trainee certificate.

Used for creating combination electrical and plumbing contractors license

This application is for any certified asbestos worker or supervisor that has lost or had their card stolen.

Used by employers to apply for self-insurance certification.

Used by self-insured employers to participate in the Orthopedic & Neurological Surgeon Quality Pilot

This form is used by experienced claims adjudicators for applying to take the Self-Insurance Claims Administrator Test.

Employer Application for Special Certificate to Employ A Vocationally Handicapped Worker at at Subprevailing

Employer Application for Special Certificate to Employ at A Subminimum Wage Rate.

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)

To apply for an insignia for a recreational vehicle.

Application used to get an telecommunications contractors license.

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.

To request access to L&I's EPIS - Miscellaneous Accounts

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)

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.

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.

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.

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.

Covers 03A, 06B, 07A, 07B, 07C, 07D, 07E, and 10 specialty licenses.

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.

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.

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.

Poster: Introduces apprenticeship, especially for younger people. Promotes the benefits of apprenticeship and includes contact information to learn more.

Used by the registered apprenticeship progam to setup an agreement with the apprentice.

Example: Used for tracking applicants for an apprenticeship program. Registered Apprenticeship Programs use their own forms.

Used to file a complaint on a apprenticeship program, committee, training agent, etc. NOT be used by Apprentices appealing Committee Decisions.

Used by apprenticeship programs/sponsors as part of the process of getting new programs/standards/occupations approved.

Glossary of terms used with Apprenticeship Related Supplemental Instruction (RSI) Plan Review form amd RSI Plan.

Used to allow an apprentice to transfer from a Washington State Registered apprenticeship program to another Washington State Registered program.

To update or correct the IME's contact, availability, qualificaitons and/or exam sites.

Used to allow an employer to train apprentices as part of a Registered Apprenticeship program.

Fact sheet: Presents facts and resources to help employers and parents keep teen workers safe on the job.

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.

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.

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.

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.

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.

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.

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).

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.

Used by a self-insured employer as an option to provide collateral for a total permanent disability claim.

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.

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.

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.

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.

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.

Used by pensioner to authorize L&I to deposit the pension payment to any designated financial institution.

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

Used by employers to give authorization to their accountants to submit quarterly reports in their behalf.

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.

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.

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.

Fact sheet: Tells construction contactors how to protect themselves from liability for their subcontractor's unpaid workers' compensation premiums.

Fact sheet: Tells construction contractors how to protect themselves from liability for their subcontractor's unpaid workers' compensation premiums.

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.

Provides information health-care providers need to bill the Crime Victims Compensation Program for medical services.

Board of Boiler Rules Extension of Inspection Frequency 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.

Board of Boiler Rules Washington State Specials Request Form

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.

Checklist used during a Boiler Inspector's Ride Along to determine if proper procedures are being followed.

The monitoring schedule of the QA/QC of boilers by L&I inspectors and notes if in-compliance or not in compliance.

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.

Borrower Agreement Form - To open an account and borrow videos, please fill out this form.

Use this form for the inspection of spouts, suckers and similar equipment on waterfront operations

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.

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.

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.

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.

Used by injured worker to notify claim manager and request authorization to transfer care to a different doctor.

Used by injured worker to notify claim manager and request authorization to transfer care to a different doctor.

Visual reminder of the importance of wearing a hard hat. Get poster printing tips.

Sample of what the Certificate of Coverage looks like. You must order the forms you cannot download it off the internet.

Sample of what the Certificate of Coverage looks like. You must order the forms you cannot download it off the internet.

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.

To assign or unassign your status as an administrator or master.

Change Assignment of Primary Point of Contact

Used by the Elevator Section only to Change and/or Update the Primary Point of Contact for Elevator Companies

Simplified version of the Chapter 19.28 RCW - Electricians and Electrical Installations Rules

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.

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.

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.

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.

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.

Chief Inspector Clarification and Interpretation Request Form

Book: Describes the responsibilities of the attending chiropractic physician in preventing claims problems.

Use this form to say whether or not you choose to have the Cholinesterase blood tests performed.

Employers must complete this form for the employee for each periodic/follow-up test and provide a copy to the health care provider.

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.

Employers use this form to request reimbursement for the reasonable costs of training, travel, recordkeeping, and medical expenses for Cholinesterase Monitoring.

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.

Used by dependents of a deceased worker to file a claim for benefits.

Used by surviving spouse or children of a deceased worker to file a claim for benefits.

Used by surviving spouse or children of a deceased worker to file a claim for benefits.

An injured worker may submit this form if their employer has suppressed their right to file an injury claim.

Fact Sheet: Explains Class B label electrical work, scope and limitations, and provides general instructions for using Class B labels.

Used by providers to be reimbursed for services. It is NOT for use by injured workers to submit a claim to L&I.

Used by the injured worker to provide comments to L&I about their recent medical exam by an IME.

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.

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.

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.

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

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.

Construction Checklist - Safety

Construction Checklist - Safety - Spanish - Lista de verificación de seguridad en la construcción

Used by employers with no employees or worker hours to report but need an open account for contract bidding process.

Pamphlet/booklet: Explains the steps to register as a construction contractor in Washington State.

Pamphlet/booklet: Explains the steps to register as a construction contractor in Washington State.

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.

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.

The attending doctor refers an injured worker for consultation for clinical issues, 120 day consultation and/or closing, etc.

Injured worker fills this out to document possible occupational disease and to show work history.

This form is used for the surety bond for construction contractors.

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.

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.

Covers workers rights when working for a farm labor contractor.

Used by a home owner to file a complaint against a contractor.

This application is used to apply for a valid electrical permit from L&I. 4 pages.

Used by the contractor to request L&I to release assignment of account that they used instead of a surety bond.

Contractor Registration Request for Duplicate License or Address Change

Contractor Regsitration Officers/members Addendum

Pamphlet/booklet: Tells contractors what their options are and what to do if they get a Notice of Infraction (a non-criminal violation).

Used by the installer to notify L&I that a conveyance is proposed for installation in a buildiing.

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.

Quick reference card: Explains the criteria to allow a corporate officer to be exempt from industrial insurance (workers' compensation) coverage.

Form from Court Granting Permission for Employment of Minors to the employer.

An agreement between a worker and employer which states the worker's employment is principally localized in Washington state or another state.

Use this form for the inspection of cranes, derricks and materials handling devices on waterfront operations

Use this form to document the minutes of your safety meetings.

A form used by physicians, hospitals and clinics to provide information and reporting to the Crime Victims Compensation Program.

Crime Victim Worker Verification - Spanish FORMULARIO DE VERIFICACIÓN DE EMPLEO

Used by dependents of a deceased Crime Victim to determine eligibility to receive pension benefits.

Crime Victims Address Change Request

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)

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).

Used by the clinical provider to submit a request for preauthorization for payment of additional sessions.

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.

Used by the clinical provider to get preauthorization for payment of additional sessions.

Used by the clinical provider to request preauthorization for payment of additional sessions.

Crime Victims Insurer Activity Prescription Form (APF)

Used by Spanish speaking dependents of deceased crime victims who are applying for pension benefits.

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.

Large lettering: DANGER. Get poster printing tips.

Sticker: 30 inches long.

Large words: Danger, Construction Area Authorized Personnel Only. Get poster printing tips.

Picture of workers on a high rise. Get poster printing tips.

Picture of workers on a high rise. Get poster printing tips.

This document shows the steps to decertify a manufactured or mobile home.

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.

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.

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.

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.

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.

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.

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.

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.

Form to gain Department of Employment Security Tax Compliance Certification for registered Farm Labor Contractors.

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.

Form to gain Department of Revenue Tax Compliance Certification for registered Farm Labor Contractors.

Used by the pensioner to learn about direct deposit. It accompanies the Authorization for Deposit of Payments- Spanish (F242-174-909) form.

Used by the pensioner to learn about direct deposit. It accompanies the Authorization for Deposit of Payments (F242-174-000) form.

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.

Employees who believe they have been discriminated against by their employer may use this form to file a complaint.

Doctor's Worksheet for Rating Cervical and Cervico-Dorsal 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.

Picture of a guy getting hit in the head with a large metal hook. Get poster printing tips.

Pamphlet/booklet: Provides an overview of bid opportunities and processes for Washington State government with specific contact information for the Department of Labor & Industries.

Quick reference guide: Used by drywall contractors to get answers to questions about being a drywall contractor and how it relates to L&I.

Used by drywall companies to file their quarterly report. Must accompany the Supplemental Quarterly Report for the Drywall Industry (F212-051-000).

Use this form to say whether or not you choose to have the Cholinesterase blood tests performed.

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.

This form is used to notify you that your license will expire and for you to use to renew your license.

An application to receive approval from L&I to instruct electrical continuing education courses.

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.

Used to gather information from a person who was a witness to electrical work that is being investigated by L&I.

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.

Used by the manufacturer to request approval from L&I on an eletrical plan to build manufactured / mobile home(s) or commercial coaches.

Fact Sheet: Provides information for requesting electrical inspections, including telephone numbers and locations of L&I offices that handle electrical inspections.

Electrical Safety Standards,Administration, and Installation WAC 296-46B

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.

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.

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.

To apply for an electrical work permit refund. Online only.

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.

Used to show proof of a bond in the State of Washington.

To authorize L&I to accept electronically submitted bills for services provided to injured workers (3 pages).

ELEVATOR ACCOUNT DEPOSIT FOR CONTRACTOR’S OR MISCELLANEOUS ACCOUNT HOLDER’S

This is used to apply for approval of elevator related continuing education courses.

Application to become an instructor for elevator related courses.

This report is used by L&I for its five-year safety inspection of an elevator.

This form is required by L&I before they can process any changes to the ownership, physical or mailing address.

Property owner or elevator company can apply for a variance to install an elevator. 4 pages.

Elevator Mechanic and Elevator Temporary Mechanic Address/Mailing Information Update

To request a refund of the fee paid for an elevator permit.

Checklist for the elevator company/contractor to complete before the call L&I for an elevator inspection.

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.

Petition to The Court for Minor Work Permit Under Age 14 by Employer.

Covers penalties for employer wage violations. Once stock runs out in warehouse, this form will be internet only.

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.

Pamphlet/booklet: Explains the benefits of 'return to work' from the employer's perspective, describes RTW options, and provides resource and contact information.

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.

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.

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.

Used by Injured Worker to report their employment history for the past three years, and the detailed wages for each job.

Used by an organization to get on the Apprenticeship Program equal opportunity resources list or use to update their information on the list.

Quick reference card: Provides a list of employments excluded from workers' compensation coverage, including those eligible for optional coverage.

This form is to request a time extension from an unforeseen circumstances for overdue corrections for conveyances.

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.

A form to request a refund for a factory-assembled structure alteration permit.

Used by a homeowner or contactor to request a field inspection for an alteration to a manufactured or mobile home.

Fact sheet: Explains the basics of the construction lien law to help consumers protect themselves.

Fact sheet: Explains training requirements and the endorsement process for medical gas piping installers.

Fact sheet: Explains plumber classifications, certification requirements, including required exams, and the application and renewal processes, including continuing education requirements.

This booklet defines the work plan requirements you must meet for fall protection.

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.

Covers Farm Labor Contracting Rules for licensing and revocation, violations and legal procedures, and penalties.

Farm Labor Contractor assignment of account or tme deposit for employee

Farm Labor Contractor Certified Payroll

Farm Labor Contractor's Checklist to ensure compliance.

Used to file a complaint against a Farm Labor Contractor, landowner, employer, or other where a possible infraction is concerned.

What Farm Labor Contractors need to know to Register for a License.

Notarized farm labor contractors bond coverage.

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.

Instructions for filing suit against an electrical contractor

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.

Sticker: No size available

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.

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.

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.

Used to file a complaint against a Farm Labor Contractor, landowner, employer, or other where a possible infraction is concerned.

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.

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.

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.

Tips on deep frying safety. Get poster printing tips.

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.

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.

Used by providers to bill L&I for reimbursement.

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.

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.

Large words that say: Getting killed is easy. Staying alive is work. Get poster printing tips.

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.

Sticker: No size available

Used by organizations to set up an agreement with L&I authorizing their participation in retrospective rating.

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.

Guide for Payroll Service Providers Bulk Filing Worker's Compensation Quarterly Reports

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.

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.

Hazard Documentation Worksheet for use by L&I compliance staff to describe, measure and comment on workplace hazards.

Hearing Aid Purchase and Repair Authorization Requests

Used by the attending doctor to determine hearing loss.

This is a list of the rights and conditions when an injured worker applies for hearing aids.

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.

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.

Pamphlet/booklet: Answers questions about Washington State's Crime Victims Compensation Program, who may be eligible for benefits and how to apply.

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".

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".

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."

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."

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.

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.

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.

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.

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.

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.

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.

Used by injured worker to report their employment history for the past three years and the wages at each job.

Injuried worker fills out this document to show more work history. This form goes with Occupational Disease & Employment History (F242-071-000).

Inspection sheet for boiler inspectors. 4 pages.

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.

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.

This variance request applies only to the installations performed by a previous owner and does not apply to any home during the warranty period.

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.

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.

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.

Fact sheet: Explains how an injured worker can protest decisions on his/her claim and gives deadlines for taking action.

Pamphlet/booklet: Provides safety tips and interesting facts to promote safe use of elevators, escalators and moving walks.

To be submitted when a valve is changed or a seal is broken.

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

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.

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.

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.

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.

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.

Used for the reporting of incident with boilers or a pressure vessels.

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.

Used by the injured worker to provide comments to L&I about their recent medical exam by an IME.

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.

Template used by a doctor during an independent medical exam.

List the locations where the doctor does independent medical exams on a regular basis.

Independent Medical Examination Fax Cover Sheet

Used by employers to set up an agreement between them and L&I authorizing their participation in retrospective rating.

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.

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.

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.

Your answers to these questions will be used to assist in evaluating your damages if a claim is made against a liable third party.

Continuation sheet to apply for an insignia.

Used for installation application for elevators (new, renewals, and alterations)

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.

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.

Instructions in Spanish for completing the form F245-072-000 Statement for Miscellaneous Services

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).

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

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.

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.

Checklist used for the filing of Prevailing Wage Complaints by "Interested parties" ONLY.

Form to gain Internal Revenue Service Tax Compliance Certification for registered Farm Labor Contractors. Now includes IRS form 8821 Tax Information Authorization.

Used when an interpreter is appointed to interpret for an injured worker during their medical visits.

To notify L&I on any electrical work that you think is illegal.

Used by a self-insurer to provide collateral for its program only if it has a net worth in excess of $500 million.

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.

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.

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.

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.

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.

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.

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.

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.

This form is used to renew a plumber certification, plumber trainee or medical gas installer certification.

Pamphlet/booklet: Describes the process for conducting an annual safety test of a residential water heater. Includes illustrations.

Picture of two keys with the words 'Skills' and Knowledge' on them. Get poster printing tips.

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.

Cartoon of a guy carrying a large lock and key with the words 'Know Your Lockout Tagout Safety Procedures'. Get poster printing tips.

This lists information about the agricultural information that can be found on the L&I website. It also has phone numbers to pertinent information.

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)

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.

Labor and Industries Prosthetic Device Request Form

Picture of a ladder with safety tips on the rungs. Get poster printing tips.

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.

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.

Letter of Intent for School Enrollment - Spanish CARTA DE INTENCIÓN DE REGISTRO EN UNA ESCUELA

Fact sheet: Explains licensing and testing requirements for mechanics who work on elevators and for contractors who install, repair or maintain elevators.

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.

Quick reference card: Reviews the requirements for members or managers of limited liability companies to be exempt from workers' compensation (industrial insurance) coverage.

Farm Labor Contractor's Checklist to ensure compliance.

This is for Registered Apprenticeship Programs to record Good Faith Effort activities in accordance with their Registered Apprenticeship Standards (Equal Employment Opportunity Plan)

Use this two part form for employers to record work locations and emergency rescue info and for holding safety meetings for each new jobsite

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.

This checklist is designed to be generic in content and may not include all requirements for your particular installation.

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.

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.

Used by the employer as a quick reference guide to explain which maritime jobs may or may not be covered by L&I.

Used by a licensed massage practitioner/clinic to request authorization for outpatient massage therapy services for L&I claims.

Master Level Counselor Provider Account Application for Crime Victims

Large words that say: Getting killed is easy. Staying alive is work.

Used by an employer to be submitted with the Employer's Quarterly Report for Industrial Insurance as a supplemental reporting form.

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.

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.

Used to order L&I medical forms.

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.

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.

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.

Manual: This manual is for providers who bill the Crime Victims Compensation Program for mental health services for crime victims.

Covers Washington State Minimum Wage Law.

Covers exemptions to Washington state minimum wage law.

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.

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.

Mobile Cranes/Derricks Worksheet for Construction Industry

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.

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.

L&I Inspection report on the QA/QC manual of a company regarding boilers.

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.

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.

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.

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.

Use this form for noting any deficiencies of cranes, derricks, material handling devices, spouts, suckers and similar equipment.

Notice of Independent Medical Exam No-Show or Late Cancellation

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.

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).

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.

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.

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.

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.

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.

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.

L&I sends this form to notify the local agencies when a modular/moblie home is being built within a county or city limits.

Injured worker fills this out to document possible occupational disease and to show work history.

Injuried worker fills out this document to show more work history. This form goes with Occupational Disease & Employment History (F242-071-000).

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.

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.

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.

Used by a therapy provider/clinic to request authorization for outpatient occupational or physical therapy services for L&I claims.

Book: Provides information and tools to analyze office jobs, find problems and develop ergonomic solutions.

OJT Accountability Agreement in Spanish

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.

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.

On-The-Job Training (OJT) Worksheet for Vocational Providers

This card is used by an OJT Apprenticeship program ONLY. To recieve this form, you must contact the Apprenticeship Section.

Used to report the work hours for an on-the-job training employee.

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.

Fact sheet: Introduces L&I's new online reporting system for industrial insurance quarterly reports. Explains the differences between Quick File and Deluxe File and compares these two options along with paper filing.

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.

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).

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.

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.

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.

Booklet: Explains what happens when an individual selects "Option 2" and choose not to participate in the approved training plan.

Used by the owner for red tagging a unit that is to be placed or to remain out of service.

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.

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.

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.

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.

Large lettering: PELIGRO

Large words: Peligro Área en Construcción Solamente Personas Authorizadas. Get poster printing tips.

Pamphlet/booklet: Answers the most common questions about pension benefits under Washington’s workers’ compensation system.

Pamphlet/booklet: Answers the most common questions about pension benefits under Washington’s workers’ compensation system.

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.

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.

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.

Used by occupational and physical therapy providers as an optional reporting format for a Performance-based Physical Capacities Evaluation.

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.

This form is used by applicants applying for a charter boat operators license to have completed by a physician for an operators license

The physical / occupational therapist uses this report to identify the clinical goals and return to work objectives of the injured worker.

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).

A manufacturer of factory-built structures and/or commercial coaches uses this form to submit plans to L&I for review.

Used in requesting a plan approval for Conversion Vendor or Medical Unit factory-assembled structures.

Plans to build recreational vehicles or park trailers need approval from L&I. This form is used as part of the approval process.

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.

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).

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.

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.

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.

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.

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.

This form is used by the course sponser to submit continuing education courses for plumber certification.

Plumber Request for Change of Address

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.

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.

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).

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

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

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

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

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.

Picture of hard hats. Get poster printing tips.

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.

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.

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.

Pamphlet/booklet: Helps self-insured employers understand and prepare for an audit.

Employees use this complaint form to report work place conditions which jeopardize workers safety and health.

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

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.

Information on how to prevent slips and falls with your footwear, housekeeping and also some general awareness tips. Get poster printing tips.

Describes the process for getting approval of new or revised RSI for new apprenticeship programs/standards/occupations.

Used to record individual equal employment opportunity activities conducted by Apprenticeship Programs.

This application is used to apply for a valid electrical permit. 5 pages.

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.

For leave from work complaints: Download and complete a Protected Leave Complaint form (F700-144-000)

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.

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.

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).

Used by providers (Orthopedic, Neurological and Hand Surgeons) to participate in the Orthopedic and 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.

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.

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.

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

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.

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.

Sticker: 8.5 inches X 3.5 inches

Sticker: 5 1/2 inches X 2 1/8 inches

Sticker: 5.5 inches X 2.15 inches

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.

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.

Instructions for filling out the quarterly statement of supplemental benefits.

Used by self-insured employers to report their quarterly statement of supplemental benefits.

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.

Used by employees who believe they have been discriminated against by their employer may use this form to file a complaint.

An injured worker may submit this form if their employer has suppressed their right to file an injury claim.

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.

Fact sheet: Provides 10 tips for safer lifting. Contains illustrations.

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.

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.

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.

Used by dependents of a deceased worker to file a claim for benefits.

Quick reference card: Identifies the type of records employers, including construction contractors, need to keep to allow L&I to compute premiums.

This form is for employers to use to keep records on every employee.

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.

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).

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.

Used to Refund Money to L&I to correct your account REFUND NOTIFICATION

Used by the Registered Apprenticeship Program to update their address or mailing information. (Note: This does update your program standards information.)

This is a fillable version of the Registered Contractot Card

Used to track apprentices/trainees on-the-job training 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.

This is a sample of a release of lien by a contractor or a subcontractor.

Renewal Application for Contractor Registration

Used by Elevator Companies to renew their Contractor License.

Used by elevator mechanics to renew their license if they do not want to use the on-line "Get or Renew a License".

To request a permit to use a rental boiler at one location only.

Large words: Report All Injuries Promptly. Get poster printing tips.

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.

Large words: Report All Injuries Promptly. Get poster printing tips.

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.

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.

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.

Used to request a duplicate elevator license or a duplicate operating permit for a conveyance.

This form is to request L&I to release archive records in the contractors registration section.

To request a cancellation of a new apprenticeship committee which never has a "Request for New Standards" approved by the WSATC

Used for cancelling an apprenticeship program.

Used by electrical licensee to notify L&I of an address change.

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.

Used by workers, workers' representatives, employers or employers' representatives to request claim information from L&I.

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.

This form is used to request a replacement certificate for a plumber or plumber trainee.

Request for Duplicate Elevator Mechanic License

To request a duplicate of your Washington state electrical license or certificate.

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.

Used to establish a new apprenticeship committee and list it's employer/employee representatives.

Request for new apprenticeship standards.

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.

Used by vocational providers to apply for preferred worker status in behalf of an industrially injured worker.

To request public records from Washington State Dept. of Labor and Industries.

Used to request copies of Certified Payrolls for prevailing wage projects.

Used to request revision of committees to include changing the title of the standards, sub-committees, and training directors/coordinators.

Used to request a revision of standards except for committee members.

Used by immediate family members of homicide victims to request mental health counseling.

Use this form to obtain your taxpayer ID number.

Used by a provider assisting victims of crime to obtain a taxpayer ID number.

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.

Use this form to make reservations of safety and health videos.

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.

Fact Sheet: Download this checklist to help with the safety orientation of new restaurant employees.

Pamphlet: Provides information about how employers can enroll in a Retrospective Rating program to lower claim costs and reduce workers' compensation experience factor.

Tips on handling cash and how to have a safer restaurant or retail environment. Get poster printing tips.

Roof Affidavit

Safety tips on using a fork lift. Get poster printing tips.

For use by consultants to evaluate employers' accident prevention programs. Use this form for large employers (more than 50 employees).

For use by consultants to evaluate employers' accident prevention programs. Use for businesses with less than 50 employees).

Pamphlet: Introduces the center and available services. You can borrow safety training videos and DVDs and order workplace posters. Also contains contact information.

Use this form to file a complaint when you feel you've been discriminated against or discharged for reporting a workplace safety hazard.

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

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.

A supervisor having a discussion with his crew. Get poster printing tips.

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

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.

Used by vocational counselors to test an injuried worker's skills and abilities.

Sample of a job offer letter from a business to an injured employee.

Used by vocational rehabilitation counselors (VRCs) to document the physical demands of jobs.

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.

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.

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.

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.

Used by department-approved claims administrators to report course completion for obtaining continuing education credit.

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.

Used by interested parties to register to attend continuing education courses provided by the L&I Self Insurance Section.

Used by employers applying to become self-insured to describe their proposed workers' compensation program.

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

Book: Explains the technical requirements for participating in SIEDRS, the Self-Insurance Electronic Data Reporting System

Used by only self-insured employers or their representatives to report initial time loss payments or to request interlocutory, wage, overpayment or closure orders.

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).

Used by self-insured employers, their representatives, and vocational counselors to summarize the outcome of a vocational rehabilitation plan when submitting the closing report.

Used to provide excess insurance for a self-insurance program.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Used to provide collateral for a self-insured program.

Used by self-insured employers as an option to provide collateral for a permanent total disability claim.

Pamphlet/booklet: Describes the work of the Safety and Health Assessment & Research for Prevention (SHARP) Program, which conducts long-term industry search to improve worker health and safety.

Used by L&I inspectors when they inspect boilers.

This is a data change request form. F207-193-000 is the Self-Insurance Electronic Data Reporting System (SIEDRS) Enrollment Form

Picture of a large eye with some content on when to use eye protection. Get poster printing tips.

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.

Used by only self-insured employers and their representatives to calculate and report injured workers’ wages and time loss compensation rates.

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.

Used by self-insured employers to request reimbursement from L&I for cost-of-living-adjustments paid to injured workers.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Used by the Crime Victims Compensation Program providers for reimbursement of Mental Health Services.

Used to bill L&I for reimbursement of home nursing services.

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.

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.

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.

Used by Crime Victims Compensation Program providers to bill for pharmacy services. Crime Victims Compensation Program providers are required to bill using this form.

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.

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).

Pictures a guy under a suspended wooden carton. Get poster printing tips.

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.

Structural Inspection Request Questionnaire

Fact sheet: Covers availability, limitations and cost of Washington State's optional workers' compensation coverage for student volunteers.

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.

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.

This form is to be used to purchase the CD ROM of registered construction contractors, registered electrical contractors, plumbers and electricians.

Suggestions on how to have successful apprenticeship committee meetings.

This summary is on employment laws relating to the agricultural industry.

Supervisors use this form to document information from an accident or injury.

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.

Used by drywall companies to file their quarterly report. Must accompany the Drywall Industry Owner/Sub-Contractor Report (F212-050-000).

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.

Pamphlet/booklet: Briefly reviews the symptoms and causes of work-related asthma and explains prevention and treatment approaches.

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.

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.

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.

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.

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.

This temporary license is limited to the mechanical and electrical operation, construction, installation, alteration, maintenance, inspection, relocation and repair of conveyances.

Used by L&I to assign industrial insurance classifications for workers of temporary help agencies.

Shows ten tips on handling a knife safely. Get poster printing tips.

Tips on how to avoid burns while cooking. Get poster printing tips.

To be filled out by the injured worker who wants to return hearing aids.

ASME A17.1 requires periodic tests on various types of elevator equipment. This form is used as documentation to test hydraulic elevators.

ASME A17.1 requires periodic tests on various types of elevator equipment. This form is used as doucmentation to test traction elevators.

A licensed elevator mechanic shall perform this test once a year and mail a copy to L&I.

Book: Aids in understanding Washington State's workers' compensation classification system and how classifications are applied to different types of businesses.

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.

Picture of a guy with Saftey Policy and Rules in his hand. Get poster printing tips.

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.

Used by third party attorneys to calculate distribution of proposed settlements in third party claims.

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.

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.

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.

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.

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.

Injured workers use this form to request reimbursement for travel expenses used to receive treatment, retraining and/or vocational services.

Used by hospitals to bill L&I for inpatient/outpatient services. This version includes NPI number.

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.

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.

Employer application request for a variance from employment standards for non minor employees.

Employer uses this application for requesting a variance to employment regulations for minors.

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.

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.

Used by the student and a school official each quarter to verify school enrollment.

Verificiation of School Enrollment - Spanish VERIFICACIÓN DE REGISTRO EN LA ESCUELA

For use by crime victims requesting time-loss compensation

Routing slip that accompanies the Vocational Services Closing Cover Sheet (F252-028-000) which is used to close vocational services to an injured worker.

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)

Vocational Questionnaire/Work History for use by Vocational Providers serving injured workers.

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.

Injured worker agrees to the ownership terms of the tools and/or equipment purchased as part of their training plan by L&I.

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.

Employer uses this to show time worked and wages earned for an employee.

Timeless reminder to walk, don't run, showing a banana peel. Get poster printing tips.

Used by the bond company to change the address of the contractor's business.

Used by the bond company to amend the amount of the contractor's bond.

Used by the bond company to change the effective date of the contractor's bond.

Used by the bond company to show a change in the business structure of a contractor's business.

Used by the bond company to change the contractor's business license number.

Used by the bond company to change the name of the contractor's business.

This rider is intended to be used in conjunction with a bond.

Poster: Lists the minimum wage and basic facts about minimum wage. Get poster printing tips.

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.

Deductions for current & terminated employees and employer liability for paying less than required.

Covers compensation for employees in Washington State working overime.

Booklet: Contains the prevailing wage laws (RCWs) and rules (WACs) as well as plain language descriptions and contact information.

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).

Large lettering: Watch Where You Step. Get poster printing tips.

Little boy wearing his daddy's hard hat, eye protection, gloves and boots. Get poster printing tips.

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.

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.

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.

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.

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.

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.

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.

This checklist is designed to be generic in content and may not include all requirements for your particular installation.

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.

This is the NEW Worker Rights Complaint Form. IMPORTANT: The Prevailing Wage Complaint form is now F700-146-000.

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.

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.

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.

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.

Fact sheet: Explains workers' legal right to file a workplace injury claim and how to file a complaint if discrimination has occurred.

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)

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.

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.

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.

Pamphlet/booklet: Explains a worker's rights and responsibilities under industrial insurance law. Describes benefits and how to file a claim.

Pamphlet/booklet: Explains a worker's rights and responsibilities under industrial insurance law. Describes benefits and how to file a claim.

Pamphlet/booklet: Explains a worker's rights and responsibilities under industrial insurance law. Describes benefits and how to file a claim.

Pamphlet/booklet: Explains a worker's rights and responsibilities under industrial insurance law. Describes benefits and how to file a claim.

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.

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.

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.

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.

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.

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.

Pamphlet/booklet: A pocket-sized bilingual booklet to encourage agricultural workers to keep track of their daily work hours and earnings.

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.

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.

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.

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.

Pamphlet/booklet: Briefly reviews the symptoms and causes of work-related asthma and explains prevention and treatment approaches.

Pamphlet/booklet: Briefly reviews the symptoms and causes of work-related asthma and explains prevention and treatment approaches.

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.

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.

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.

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.

Form used to compute Your Workers' Compensation premiums. Page 2 has rate notice definitions. Sample only.

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.