Used by medical providers when reporting initial treatment for an industrial injury or occupational disease for a self-insured claim. Medical providers treating self-insured workers, self-insured businesses, or their third party claims administrators may order copies of this form. Click the "order it" button to request paper copies. If you download the MS Word form, also download the PDF file with instructions on use of the MS Word form. The first file is an Office 2003 MSWord document with a .doc extension. The second file is an Office 2007/2010 version, with a .docx extension.

You can submit a Report of Accident (ROA) online https://secure.lni.wa.gov/home This form is not on the internet. If you are an injured worker, ask your doctor for a copy of this form. Order F242-130-999 from the warehouse to receive the instructions in Spanish to complete the form in English.

Provided to workers by the self-insured businesses or their third party claims administrators to report an industrial injury or occupational disease. This form is not on the internet. If you are an injured worker, ask your employer for a copy of this form. Self-insured businesses or their third party claims administrators may order copies of this form. Cllick the "order It" button below to order paper copies or request the form in MSWord.

Handout (4.25 x 6): Explains to workers why and how to file an accident report online or by phone following an injury; also reminds them to stay in contact with employer and L&I.

Poster (8.5 x 11): Explains to workers why and how to file an accident report online or by phone following an injury and reminds them to stay in contact with employer and L&I.

Used to order L&I medical forms.

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).

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.

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