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Agreement of Assumption and Guarantee of Workers' Compensation Liabilities (Certified Self-Insurer)
Form
F207-040-001  
Amendment of Irrevocable Standby Letter of Credit
Form
F207-112-111  
Application for Inclusion on List of Eligible Attorneys
Form
F249-017-000  
Application for Loss of Earning Power (LEP) - Compensation Medical
Form
F242-208-000

World Language(s):
English/Español
Español  
Authorization for Deposit of Payments
Form
F242-174-000

World Language(s):
English/Español  
Authorization to Release Claim Information
Form
F101-010-000

World Language(s):
Español  
Autorización para proveer información de reclamos
Form
F101-010-999

World Language(s):
Inglés  
Continuación del Historial de Trabajo y de Enfermedad Ocupacional
Form
F242-071-911

World Language(s):
Inglés  
Cuestionario para beneficios de pensión
Form
F242-393-999

World Language(s):
Inglés  
Cuestionario sobre la pérdida del sentido auditivo en el trabajo
Form
F262-016-999

World Language(s):
Inglés  
Department of Labor and Industries Home Modification Acknowledgement of Responsibilities
Form
F247-003-000

World Language(s):
Español  
Drywall Contractors
Form
F214-024-000  
Employment History Form
Form
F242-109-000

World Language(s):
Español  
Formulario de estado de empleo (Formulario de verificación de empleo)
Form
F242-052-999

World Language(s):
Inglés  
Formulario de historial de empleo
Form
F242-109-999

World Language(s):
Inglés  
Historial de trabajo (enfermedad ocupacional)
Form
F242-071-999

World Language(s):
Inglés
Español  
How to Protest a Department of Labor and Industries Decision / Cómo protestar una decisión en su reclamo del Departamento de Labor e Industrias (English/español)
Publication
F242-363-909  
Irrevocable Standby Letter of Credit
Form
F207-112-000  
Job Modification Assistance Application
Form
F245-346-000

World Language(s):
Español  
Memorandum of Understanding Irrevocable Standby Letter of Credit
Form
F207-113-000  
Memorandum of Understanding
Form
F207-129-000  
Need a Doctor?
Publication
F160-006-000

World Language(s):
Español  
Notice of Occupational Disease or Infection
Form
F242-243-000  
Notificación de decisión de cierre con discapacidad parcial permanente para empleadores autoasegurados - DISCAPACIDAD PARCIAL PERMANENTE (PPD) - SIN TIEMPO PERDIDO (NTL)
Form
F207-165-999

World Language(s):
Inglés  
Notificación de decisión de cierre con discapacidad parcial permanente para empleadores autoasegurados -DISCAPACIDAD PARCIAL PERMANENTE (PPD) - CON TIEMPO PERDIDO (NTL)
Form
F207-164-999

World Language(s):
Inglés  
Notificación de decisión de cierre para reclamos únicamente médicos para empleadores autoasegurados
Form
F207-020-999

World Language(s):
Inglés  
Notificación de decisión de cierre para reclamos de tiempo perdido para empleadores autoasegurados
Form
F207-070-999

World Language(s):
Inglés  
Occupational Disease & Employment History
Form
F242-071-000

World Language(s):
Español  
Occupational Disease Employment History Hearing Loss
Form
F262-013-000

World Language(s):
Español  
Occupational Disease Work History - Continuation
Form
F242-071-111

World Language(s):
Español  
Occupational Hearing Loss Questionnaire
Form
F262-016-000

World Language(s):
Español  
Pension Benefits Questionnaire
Form
F242-393-000

World Language(s):
Español  
Performance Based Physical Capacities Evaluation
Form
F245-023-000  
Provider's Initial Report (PIR)
Form
F207-028-000  
Quarterly Report for Self-Insured Business
Form
F207-006-000  
Reclamo para beneficios de pensión presentado por los dependientes
Form
F242-062-999

World Language(s):
Inglés  
Reclamo para beneficios de pensión presentado por el cónyuge, pareja doméstica registrada o los hijos
Form
F242-056-999

World Language(s):
Inglés  
Report of Accident (ROA) Workplace Injury, Accident or Occupational Disease
Form
F242-130-000

World Language(s):
Español  
Request for Claim Information
Form
F101-010-111  
Risk Management Consultation
Publication
F417-246-000  
Self Insurance Continuing Education Report of Course Completion
Form
F207-191-000  
Self Insurance Continuing Education Report of Course Completion
Form
F207-191-000  
Self Insurance Continuing Education Report of Course Completion
Form
F207-191-000  
Self-Insurance Continuing Education Application for Course Approval and Attendance
Form
F207-206-000  
Self-Insurance Report of Occupational Injury or Disease (SIF-5)
Form
F207-005-000  
Self-Insured Employers' Medical Only Claim Closure Order and Notice
Form
F207-020-111

World Language(s):
Español  
Self-Insured Employers' Permanent Partial Disability Closure Order and Notice - PPD-NTL
Form
F207-165-000

World Language(s):
Español  
Self-Insured Employers' Permanent Partial Disability Closure Order and Notice - PPD-TL
Form
F207-164-000

World Language(s):
Español  
Self-Insured Employers' Time Loss Claim Closure Order and Notice
Form
F207-070-000

World Language(s):
Español  
Self-Insurer Accident Report (SIF-2)
Form
F207-002-000  
Self-Insurer's Pension Bond
Form
F207-065-000  
Solicitud para cambio de dirección para pensionados
Form
F242-107-999

World Language(s):
Inglés  
Solicitud para cambio de dirección para trabajadores lesionados
Form
F242-388-999

World Language(s):
Inglés  
Statement for Miscellaneous Services
Form
F245-072-000

World Language(s):
Español  
Supplemental Agreement Third Party Pharmacy Provider
Form
F249-021-000  
Tarjeta para transferencia de caso
Form
F245-037-999

World Language(s):
Inglés  
Transfer of Care Card
Form
F245-037-000

World Language(s):
Español  
Work Status Form (formerly Worker Verification Form)
Form
F242-052-000

World Language(s):
Español  
Workers' Compensation Discrimination / Discriminación porque se lesionó en su trabajo (English/español)
Publication
F262-249-909  
Address Change Request for Injured Workers
Form
F242-388-000

World Language(s):
Español  
Assignment of Account Agreement
Form
F207-058-000  
Claim for Pension By Dependents
Form
F242-062-000

World Language(s):
Español  
Claim for Pension by Spouse or Children
Form
F242-056-000

World Language(s):
Español  
FileFast poster for workers
Poster
F242-399-000  
Frequently Asked Questions about Job Modifications
Publication
F245-057-000  
Letter of Intent for School Enrollment
Form
F242-382-000

World Language(s):
Español  
SIF-4 Self Insured Employer's Request for Denial of Claim
Form
F207-163-000  
Special Escrow Account - Amendment Agreement
Form
F207-137-000  
Verification of School Enrollment
Form
F242-055-000

World Language(s):
Español  





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