Pamphlet/booklet: Explains a worker's rights and responsibilities under industrial insurance law. Describes benefits and how to file a claim. Note: Previously titled, Workers' Guide to Industrial Insurance Benefits.

   
Also available in: Spanish

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, enforcement of WISHA rules, and consultation and education services L&I provides. Previously titled A Guide to WISHA

Pamphlet/booklet: Provides an overview of the Washington Industrial Safety and Health Act (WISHA), worker and employer rights and responsibilities, enforcement of WISHA rules, and consultation and education services L&I provides. Previously titled A Guide to WISHA

Stand-alone document that can be used with all Ability to Work Assessment outcomes.

Used by rehabilitation providers to document in a vocational assessment that a worker needs further services.

This document provides the facts necessary to make an informed decision regarding vocational retraining benefits and explains the responsibilities you and your vocational counselor (VRC) have.

This document provides the facts necessary to make an informed decision regarding vocational retraining benefits and explains the responsibilities you and your vocational counselor (VRC) have. For OJT retraining plans, please refer to form F280-029-000.

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.

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.

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_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.

Info card: Provides information on the Employer's Intro to L&I workshop, including statewide schedule of workshops. Designed for employers and managers, the workshop covers a number of topics, including workers' compensation insurance, workplace safety, and overtime.

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 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.

Used by a spouse or dependent that was chosen by the deceased worker to receive a survivor benefit. At the time the worker was determined to be totally permanently disabled he/she made a decision to leave a survivor benefit to a spouse or dependent if the worker dies.

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.

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.

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

Fact sheet: Explains how employers could be liable for unpaid workers' compensation premiums, unpaid wages, damages and civil penalties when hiring a farm labor contractor. Outlines ways to protect against potential liability.

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

Used by a spouse or dependents of a deceased worker. The workers' fatal accident or occupational disease incurred in the course of their employment. This application is needed to determine if applicant(s) is/are entitled to a survivor benefit.

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 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 totally permanently disabled worker. This form must be completed, signed, notarized and returned to L&I within 30 days for non interruption of benefits.

To authorize L&I to accept electronically submitted bills for services provided to injured workers (2 pages).

Used by employer of record to prepare a written job description for a light-duty job, transitional, 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.

General billing information for those providers that bill the department.

Hearing Aid Repair Authorization Requests. If you need to purchase or replace a hearing aid, fax all of the information required by Medical Aid Rules and Fee Schedule (MARFS) including the Hearing Services Worker Information (F245-049-000) to 360-902-6252.

Used by Spanish speaking health-care providers to communicate an injured worker's status, physical capacities, inability to work (time-loss) and treatment plans.

Utilizado por proveedores de cuidado de la salud que hablan español para indicar la condición actual del trabajador lesionado, restricciones físicas, certificación de tiempo perdido y planes de tratamiento.

Used by health-care providers to communicate an injured worker's status, physical capacities, inability to work (time-loss) and treatment plans. To print an APF, click on the title of the form in the box above.

Pamphlet/booklet: Explains structured settlement and provides an overview of eligibility and the application and approval processes. The audience for this pamphlet is injured workers who might be eligible.

Answers questions persons with a terminal illness may ask about benefits from L&I.

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

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

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 independent medical exams in Washington's workers' compensation system. Beginning July 1, 2012, free Category I CME credits are available for completing the self-assessment associated with this handbook. Go to www.Imes.Lni.wa.gov and click on Medical Examiners Handbook for information on the exam. 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.

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

Mobile Cranes/Derricks Worksheet for Construction Industry

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.

OJT Accountability Agreement in Spanish

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.

For legal guardians and school officials to approve the hours and work activities for a minor employee to work according to terms listed by the employer. The Special Variance allows additional hours of work for 16- and 17-year-olds and is described on the form. All parties must sign to approve the hours of work for a minor regardless of the number of hours listed. 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.

Pamphlet/booket: Answers the most common questions about pension and survivor benefits under Washington's workers' compensation program.

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.

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 the Washington State Prevailing Wage Law booklet.

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.

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.

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 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.

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

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

A form for Providers to submit disputes to the department regarding payment of medical provider bills

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 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.

This bill form is used by providers and injured workers to bill the department for services such as dental care; glasses; medical equipment; nursing home services; interpreter services; services workers pay for out of pocket; and other services. Information on how to bill the department can be found in the General Provider Billing Manual (F248-100-000).

Bill form for prescription charges. May be used by a pharmacy to submit drug charges, or by a worker to request reimbursement for prescriptions paid out of pocket. See the General Provider Billing Manual (F248-100-000) for information on completing this form.

Use this form to submit your taxpayer ID number. Note: Register now for direct deposit available at a later date.

Pamphlet/booklet: Provides an overview Stay at Work, a financial incentive program that encourages Washington employers to find light-duty or transitional jobs for workers recovering from on-the-job injuries. Includes information on eligibility, how to apply, and where to get more information.

Pamphlet/booklet: Provides an overview Stay at Work, a financial incentive program that encourages Washington employers to find light-duty or transitional jobs for workers recovering from on-the-job injuries. Includes information on eligibility, how to apply, and where to get more information.

To record the training costs. For use only with plans approved after 1/1/2008.

To record the costs for transportation. For use only with plans approved after 1/1/2008.

Bill form for use by workers to request reimbursement for authorized travel expenses.

Pamphlet/booklet: Explains a worker's rights and responsibilities under industrial insurance law. Describes benefits and how to file a claim. Note: Previously titled Una gua de los trabajadores para beneficios del seguro industrial.

Pamphlet: Provides an overview of employers' responsibilities for workplace safety and health in Washington State. Covers free L&I services, including workplace consultations, online training and prevention resources and required posters. Intended for new businesses or businesses hiring employees for the first time.

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.

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 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.

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.

Used by a spouse or dependent that was chosen by the deceased worker to receive a survivor benefit. At the time the worker was determined to be totally permanently disabled he/she made a decision to leave a survivor benefit to a spouse or dependent if the worker dies.

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

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

Description: This guide details the HIPAA ASC X12N 005010 format structure for EDI and provides information regarding electronic billing To the department via Provider Express Billing (PEB)

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.

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).

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

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 an online self-assessment. Go to www.CMECredits.Lni.wa.gov.

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

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.

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.

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

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

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

Used by a spouse or dependents of a deceased worker. The workers' fatal accident or occupational disease incurred in the course of their employment. This application is needed to determine if applicant(s) is/are entitled to a survivor benefit.

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

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.

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.

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

Instructions for completing a Direct Entry bill to submit to the Crime Victims Compensation Program. Direct entry allows you to submit or adjust bills using a free online billing form through Provider Express Billing (PEB).

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 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.

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.

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

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. For use in place of Minimum Data Set (MDS) 3.0 beginning October 1, 2010.

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

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.

This guide details the HCFA proprietary format structure and provides information regarding electronic billing to the department via Provider Express Billing (PEB).

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.

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.

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.

Pamphlet/booklet: Explains structured settlement and provides an overview of eligibility and the application and approval processes. The audience for this pamphlet is injured workers who might be eligible.

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.

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

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.

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.

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.

Quick reference card: Reviews the requirements for members or managers of limited liability companies to be exempt from workers' compensation (industrial insurance) coverage. This information is part of the publication, Workers’ Compensation Record Keeping and Report Guides.

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 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 to order L&I medical forms.

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.

Used by non-accredited or unlicensed training providers in order to be reviewed for approval to become a training provider for Washington injured workers. Must be submitted with the Provider Account Application (F248-011-000).

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.

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.

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

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.

This guide details the HIPAA ASC X12N 004010 format structure for 835 Pharmacy Remittance Advice and provides information regarding electronic billing to the department via Provider Express billing (PEB)

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

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 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.

To record the work plan time. For use only with plans approved after 1/1/2008.

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).

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.

The provider network agreement for participation in the health care provider network for injured workers covered by Washington State Fund and self-insured employers.

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.

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

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.

Schedule of Future Payments for the Balance of the Permanent Partial Disability Award.

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 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.

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

Bill form for use by pharmacies and home infusion companies to submit compound drug charges. This form is for drug charges only, and is filled out by the pharmacist. See the Pharmacy Billing Instructions (F248-021-000) for information on completing this form.

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

Bill form for providers that bill the department for claim-related retraining and job modification services. See the Retraining and Job Modification Billing Instructions (F248-015-000) for information on completing this form.

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.

Pamphlet/booklet: Explains structured settlement and provides an overview of eligibility and the application and approval processes. The audience for this pamphlet is self-insured employers. Employers covered by the state's workers' compensation program should read Publication F240-004-000.

Pamphlet/booklet: Explains structured settlement and provides an overview of eligibility and the application and approval processes. The audience for this pamphlet is employers covered by the state's workers' compensation program. Self-insured employers should read Publication F240-005-000.

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

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.

This guide details the HIPAA ASC X12N 004010 format structure for EDI and provides information regarding electronic billing to the department via Provider Express billing (PEB).

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

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

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

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 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.

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

Fact sheet: Summarizes workers' rights and responsibilities regarding minimum wage, pay, work hours and overtime and explains how to file a wage complaint. Includes answers to several commonly asked questions.

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)

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.

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

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.