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.

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

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.

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

Used by employers to apply for self-insurance certification.

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

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.

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.

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.

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

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.

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

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.

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.

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.

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.

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

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.

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 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 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.

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 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.

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.

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.

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.

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 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.

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.

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

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.

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.

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.

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.

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.

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.

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).

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.

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.

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

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.

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

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

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

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.

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.

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

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.

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.

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.

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.

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.

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.

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

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

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.

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.

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.

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

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.

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

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

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

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.

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

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.

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.

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

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

Used by self-insured employers or their representatives to notify an injured worker that the employer or representative is requesting that L&I deny their claim.

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

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.

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.

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 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 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.

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 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.

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

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

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.

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

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

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

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.

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.

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: 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.