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Quarterly Statement of Supplemental Benefits Paid for Self-Insured Employers

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



Form
F207-011-000
 
Quarterly Statement of Supplemental Benefits Instructions

Instructions for filling out the quarterly statement of supplemental benefits.



Form
F207-011-111
 
Special Escrow Agreement
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.

Form
F207-039-000
 
Agreement of Assumption and Guarantee of Workers' Compensation Liabilities - Application of Certification

Used by an employer to apply for self-insurance.



Form
F207-040-000
 
Agreement of Assumption and Guarantee of Workers' Compensation Liabilities (Certified Self-Insurer)

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.



Form
F207-040-001
 
Assignment of Account Agreement
Used by a self-insured employer as an option to provide collateral for a total permanent disability claim.

Form
F207-058-000
 
Self-Insurer's Pension Bond

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



Form
F207-065-000
 
Self-Insurer's Bond - Existing Liabilities
Used to provide collateral for a self-insured program.

Form
F207-068-000
 
Self-Insured Employers' Time Loss Claim Closure Order and Notice

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.



Form
F207-070-000

Alt Language(s):
Español
 
A Guide to Workers' Compensation Benefits For Employees of Self-Insured Businesses

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.



Publication
F207-085-000

Alt Language(s):
Español
 
Guía de Beneficios de Compensación para los Trabajadores:  Para los Empleados de Empresas Autoaseguradas - (English) A Guide to Workers' Compensation Benefits For Employees of Self-Insured Businesses

Pamfleto/folleto: Explica a los empleados de negocios autoasegurados sus derechos y responsabilidades bajo la ley de seguro industrial.  Describe los beneficios y como  presentar un reclamo.



Publication
F207-085-999

Alt Language(s):
Inglés
 
Self-Insured Employer Certificate of Excess Insurance

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



Form
F207-095-000
 
Irrevocable Standby Letter of Credit

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



Form
F207-112-000
 
Amendment of Irrevocable Standby Letter of Credit

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



Form
F207-112-111
 
Memorandum of Understanding Irrevocable Standby Letter of Credit

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.



Form
F207-113-000
 
Pension Bond Rider
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.

Form
F207-120-000
 
Annual Supplemental Surety Information

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



Form
F207-125-000
 
Memorandum of Understanding

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.



Form
F207-129-000
 
Surety Rider
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.

Form
F207-134-000
 
Special Escrow Account - Amendment Agreement
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.

Form
F207-137-000
 
Acknowledgement of Security Interest
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.

Form
F207-143-000
 
Workers' Compensation Filing Information

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.



Form
F207-155-000

Alt Language(s):
Español
 
Cómo Registrar un Reclamo para la Compensación del Trabajador con Empresas Autoaseguradas

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.



Form
F207-155-999

Alt Language(s):
Inglés
 
SIF-5A Cover Sheet: Wage Calculations

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



Form
F207-156-000
 
Self-Insured Employers' Permanent Partial Disability Closure Order and Notice - PPD-TL

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.



Form
F207-164-000

Alt Language(s):
Español
 
Self-Insured Employers' Permanent Partial Disability Closure Order and Notice - PPD-NTL

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.



Form
F207-165-000

Alt Language(s):
Español
 
Self-Insurance Vocational Services Closing Cover Sheet
Used by self-insured employers, their representatives, and vocational counselors to summarize the outcome of a vocational rehabilitation plan when submitting the closing report.

Form
F207-171-000
 
Certificate of Coverage - SAMPLE ONLY

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



Form
F211-141-000

Alt Language(s):
Español
 
Certificado de Cobertura - Ejemplo
Sample of what the Certificate of Coverage looks like. You must order the form, you cannot download it off the internet.

Form
F211-141-999

Alt Language(s):
Inglés
 
Maritime Coverage

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



Form
F212-034-000
 
Coverage Agreement

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



Form
F212-044-000
 
Drywall Industry - Owner/Sub-Contractor Report

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



Form
F212-050-000
 
Supplemental Quarterly Report for the Drywall Industry

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



Form
F212-051-000
 
Sports Teams Coverage Agreement

Used by a sports team or league covering their Washington players through an out-of-state workers' compensation insurance carrier to confirm compliance with RCW 51.12.120 and WAC 296-17-32503.



Form
F212-196-000
 
Cancellation of Elective Coverage - Sole Proprietors/Partner, Member of Limited Liability Company (LLC), Member of Limited Liability Partnership (LLP) or For-Profit Corporate Officers

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.



Form
F213-004-000
 
Cancellation of Elective Coverage for Excluded Employments

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.



Form
F213-005-000
 
Construction Industry Classification Guide

Book (loose-leaf manual): Helps contractors properly classify for workers' compensation insurance purposes the work being performed by their employees on new wood-frame building construction projects.



Publication
F213-008-000
 
Contract: Report By Landowner - Forest, Range & Timber Industry

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.



Form
F213-010-000
 
Contract: Report By Contractor - Forest, Range & Timber Industry

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.



Form
F213-011-000
 
Reforestation Contract Supplemental Report - Forest, Range and Timber Industry

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).



Form
F213-013-000
 
Reforestation Industry Continuation Sheet (Over $10,000)

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.



Form
F213-015-000
 
Student Volunteers and Workers' Compensation Coverage
Fact sheet: Covers availability, limitations and cost of Washington State's optional workers' compensation coverage for student volunteers.

Publication
F213-023-000
 
Application for Elective Coverage - Sole Proprietor, Partners, For-Profit Corporate Officers, or Member/Managers of Limited Liability Company (LLC)

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.



Form
F213-042-000
 
Application for Elective Coverage of Excluded Employments

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.



Form
F213-112-000
 
Application for Exclusion/Inclusion - Mandatory Coverage (Family Farm)

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



Form
F213-113-000
 
Record Keeping

Quick reference card: Identifies the type of records employers, including construction contractors, need to keep to allow L&I to compute premiums. This information is part of the publication, Workers’ Compensation Record Keeping and Report Guides.



Publication
F214-011-000
 
Excluded and Exempt Employments

Quick reference card: Provides a list of employments excluded from workers' compensation coverage, including those eligible for optional coverage. This information is part of the publication, Workers’ Compensation Record Keeping and Report Guides.



Publication
F214-013-000
 
Computing Worker Hours

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. This information is part of the publication, Workers’ Compensation Record Keeping and Report Guides.



Publication
F214-014-000
 
Audit Reference Card
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.

Publication
F214-020-000
 
Limited Liability Companies (LLC)

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.



Publication
F214-021-000
 
Drywall Contractors

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



Form
F214-024-000
 
Your Workers' Compensation Rate Notice - SAMPLE ONLY

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



Form
F225-004-000
 
Request for Manuals from Claims Training

Fillable form to purchase the Workers’ Compensation Adjudicator (WCA), Claims Management (CM), and Policy Manuals (all 3 manuals on 1 CD) the costs will be added up automatically, the total amount enclosed column will be the amount you need to send as payment.



Form
F241-021-000
 
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.

 



Form
F242-052-000

Alt Language(s):
Español
 
Worker Verification Form - Spanish Formulario de Verificación de Empleo

El trabajador lesionado debe completarlo si no puede trabajar debido a una lesión en el lugar de trabajo Y su empleador no le está pagando su salario completo.  



Form
F242-052-999

Alt Language(s):
Inglés
 
Verification of School Enrollment

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



Form
F242-055-000

Alt Language(s):
Español
 
Claim for Pension by Spouse or Children
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.

Form
F242-056-000

Alt Language(s):
Español
 
Claim for Pension by Spouse or Children -  Reclamo para Beneficios de Pensión Presentado por el Cónyuge, Pareja Doméstica Registrada o los Hijos (Spanish)

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.



Form
F242-056-999

Alt Language(s):
Inglés
 
Claim for Pension By Dependents
Used by dependents of a deceased worker to file a claim for benefits.

Form
F242-062-000

Alt Language(s):
Español
 
Reclamo para Beneficios de Pensión Presentado por los Dependientes

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



Form
F242-062-999

Alt Language(s):
Inglés
 
Occupational Disease & Employment History

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



Form
F242-071-000

Alt Language(s):
Español
 
Continuación del Historial de Trabajo y de Enfermedad Ocupacional

El trabajador lesionado llena este formulario para documentar una posible enfermedad ocupacional y para mostrar su historia de trabajo.



Form
F242-071-911

Alt Language(s):
Inglés
 
Historial de Trabajo (Enfermedad Ocupacional)

El trabajador lesionado llena este documento para presentar su historia de trabajo.  El formulario de continuación a esta página es F242-071-911.



Form
F242-071-999

Alt Language(s):
Inglés
Español
 
Application to Reopen Claim Due to Worsening Condition

This application is by injured workers and providers to apply to reopen an industrial injury or occupational disease claim due to worsening condition for claims that have been claims 60 days or longer.



Form
F242-079-000

Alt Language(s):
English/Español
Español
 
Beneficios de Compensación para los Trabajadores: Una guía para los Trabajadores Lesionados - English (Workers' Compensation Benefits: A Guide for Injured Workers)

Folleto: Explica los derechos y responsabilidades de los trabajadores bajo la ley de seguro industrial.  Describe beneficios y cómo presentar un reclamo.  Aviso: Anteriormente titulado, Guía de Beneficios del Seguro Industrial para los Trabajadores.  



Publication
F242-104-999

Alt Language(s):
Inglés
 
Address Change Request for Pensioners

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.



Form
F242-107-000

Alt Language(s):
Español
 
Address Change Request for Pensioners - (Spanish) Solicitud para Cambio de Direccion para Pensionados

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.



Form
F242-107-999

Alt Language(s):
Inglés
 
Report of Accident (ROA) Workplace Injury, Accident or Occupational Disease

This form is not available online. If you are an injured worker, ask your medical provider for a copy of this form or you can complete your portion of the Report of Accident (ROA) online at https://secure.Lni.wa.gov/home.

Medical providers can order the ROA and the worker instruction in Spanish from the L&I Warehouse by using the link below.
http://www.Lni.wa.gov/ClaimsIns/Providers/FormPub/ROA/OrderROA.asp



Form
F242-130-000

Alt Language(s):
Español
 
Report of Accident Instructions -- Spanish Instrucciones para el Reporte de Accidente

This document provides instructions in Spanish on how to complete the worker portion only of the Report of Accident (ROA). Please note that the Report of Accident is not available in Spanish. To order these instructions from the L&I Warehouse, please use the link below.

http://www.Lni.wa.gov/ClaimsIns/Providers/FormPub/ROA/OrderROA.asp



Form
F242-130-999

Alt Language(s):
Inglés
 
Declaration of Entitlement for Widow or Widower Benefits Under Industrial Insurance
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
F242-173-111

Alt Language(s):
Español
 
Declaration of Entitlement for Guardian Benefits under Industrial Insurance
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.

Form
F242-173-222

Alt Language(s):
Español
 
Declaration of Entitlement for Dependent of Deceased Worker Benefits Under Industrial Insurance
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.

Form
F242-173-333

Alt Language(s):
Español
 
Declaration of Entitlement for Totally Disabled Worker Benefits Under Industrial Insurance
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.

Form
F242-173-444

Alt Language(s):
Español
 
Declaración de Derechos para Viuda(o) bajo el Programa de Compensación y Beneficios para Trabajadores

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
F242-173-911

Alt Language(s):
Inglés
 
Declaración de Derechos para Padres o Tutor Bajo el Programa de Compensación y Beneficios para Trabajadores

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.



Form
F242-173-922

Alt Language(s):
Inglés
 
Declaración de Derechos para Dependiente del Trabajador Fallecido Bajo el Programa de Compensación y Beneficios para Trabajadores

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.



Form
F242-173-933

Alt Language(s):
Inglés
 
Declaración de Derechos para los Beneficios de un Trabajador Totalmente Discapacitado Bajo las Leyes del Seguro Industrial

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.



Form
F242-173-944

Alt Language(s):
Inglés
 
Authorization for Deposit of Payments

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



Form
F242-174-000

Alt Language(s):
English/Español
 
Notice to Employees -- If a Job Injury Occurs/Aviso a los empleados--Si Ocurre una Lesión en el Trabajo (English/Spanish)

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.



Poster
F242-191-909
 
How to Protest a Department of Labor and Industries Decision (English/Spanish) Cómo Protestar una Decisión en su Reclamo del Departamento de Labor e Industrias

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



Publication
F242-363-909
 
Statement for Compound Prescription

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.



Form
F245-010-000
 
Statement for Retraining and Job Modification Services

Bill form for providers that bill the department for claim-related retraining and job modification services. See the General Provider Billing Manual (248-100-000) for information on completing this form.



Form
F245-030-000
 
Transfer of Care Card

Used by injured worker to notify claim manager and request authorization to transfer care to a different doctor. Do it online! Use the online Transfer of Care



Form
F245-037-000

Alt Language(s):
Español
 
Transfer of Care Card (Spanish) Tarjeta para Transferencia de Caso

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



Form
F245-037-999

Alt Language(s):
Inglés
 
Provider Account Application - Independent Medical Examiner (IME)

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) (10 pages). If you have questions, please email balk235@lni.wa.gov or call 360-902-6815.



Form
F245-046-000
 
Independent Medical Examination (IME) Provider Exam Sites

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



Form
F245-047-000
 
Approved Independent Medical Examiner (IME) Update
To update or correct the IME's contact, availability, qualificaitons and/or exam sites.

Form
F245-051-000
 
Submission of Provider Credentials for Interpretive Services

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.



Form
F245-055-000
 
Interpretive Services Appointment Record

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

When ordering, there is a limit of 4 pads, or 100 copies total. Fax your request to the L&I Warehouse at 360-902-4525 or email whsemail@Lni.wa.gov   Include the following in your request: Your name, mailing address, and telephone number and form number F245-056-000.



Form
F245-056-000
 
Independent Medical Exam Template
Template used by a doctor during an independent medical exam.

Form
F245-058-000
 
Statement for Miscellaneous Services

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].

 



Form
F245-072-000

Alt Language(s):
Español
 
Statement for Pharmacy Services

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.



Form
F245-100-000
 
CMS 1500 (formerly L&I Health Insurance Claim form)
Used by providers to be reimbursed for services. It is NOT for use by injured workers to submit a claim to L&I.

Form
F245-127-000
 
Travel Reimbursement Request

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



Form
F245-145-000

Alt Language(s):
Español
 
Travel Reimbursement Request - (Spanish) Solicitud para el Reembolso de Gastos de Viaje

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



Form
F245-145-999

Alt Language(s):
Inglés
 
Provider's Request for Adjustment

Providers use this to report total overpayment, partial overpayment and/or underpayment by L&I.



Form
F245-183-000
 
Your Independent Medical Exam

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.



Form
F245-224-000

Alt Language(s):
Español
 
Su Examen Médico Independiente

Panfleto/folleto: Respuestas a las preguntas más comunes sobre los exámenes médicos independientes y cuándo y por qué podría requerirse que un trabajador lesionado asistiera a uno.  Incluye el formulario “Examen Médico Independiente (IME) - Solicitud para el reembolso de gastos de viaje y salario.” Este formulario es solamente para el uso de negocios autoasegurados y sus trabajadores.



Form
F245-224-999

Alt Language(s):
Inglés
 
Job Modification Assistance Application

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.



Form
F245-346-000
 
Pre-Job Accommodation Assistance Application

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.



Form
F245-350-000
 
Vocational Training Plan Ownership Agreement for Tools and Equipment

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



Form
F245-351-000
 
Provider Credentialing Change Form

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.



Form
F245-365-000
 
UB04 HCFA 1450

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



Form
F245-367-000
 
Non-Network Provider Application

Includes the F248-036-000 Statewide Payee Registration and W-9 form. For providers to complete that do not want to become a Labor and Industries network provider, or for a specialty that L&I is not accepting network applications for at this time. If you are applying to be a Labor and Industries network provider, please complete application process at www.ProviderNetwork.Lni.wa.gov



Form
F248-011-000
 
Electronic Billing Authorization

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



Form
F248-031-000
 
Statewide Payee Registration and W-9 Form

Use this form to submit your taxpayer ID number. Note: Register now for direct deposit.



Form
F248-036-000
 
Hotline Tips for Medical Services Providers
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.

Publication
F248-040-000
 
Occupational or Physical Therapy Treatment Authorization Fax Request

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



Form
F248-055-000
 
Payroll Service Provider - Quarterly Reporting Bulk Filing Enrollment Form

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.



Form
F248-343-000
 
Third Party Recovery Worksheet

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



Form
F249-006-111
 
Injured by a third party?  

Brochure: Summarizes the legal rights and options an injured worker has if a third-party action pertains to his/her workers' compensation claim. Includes the Third Party Election Form that must be completed by the worker. Note: The form must be printed, signed and mailed.



Form
F249-008-000

Alt Language(s):
Español
 
Application for Inclusion on List of Eligible Attorneys
Used by attorneys to be included on the Workers' Compensation Special Assistant Attorney General Program eligible list for Third Party claims.

Form
F249-017-000
 
Individual Retrospective Rating Plan Agreement
Used by employers to set up an agreement between them and L&I authorizing their participation in retrospective rating.

Form
F250-003-000
 
Application for Group Retrospective Rating
Used by organizations to set up an agreement with L&I authorizing their participation in retrospective rating.

Form
F250-004-000
 
Application for Group Membership & Authorization for Release of Insurance Data
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.

Form
F250-016-000
 
Medical Examiners' Handbook

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.



Publication
F252-001-000
 
Doctor's Worksheet for Rating Dorso-Lumbar & Lumbo-Sacral 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.

Form
F252-006-000
 
Hearing Impairment Calculation Worksheet
Used by the attending doctor to determine hearing loss.

Form
F252-007-000
 
Medical Device Review Request

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.



Form
F252-013-000
 
Vocational Providers Application and Notice

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) CURRENT EXISTING VOCATIONAL PROVIDER FIRMS THAT ARE ALREADY REGISTERED WITH L&I USE THIS FORM AND W-9.



Form
F252-017-000
 
Individual Vocational Provider Account Change Form

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.



Form
F252-021-000
 
Firm Vocational Provider Account Change

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.



Form
F252-022-000
 
Vocational Closing Report Routing Sheet

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



Form
F252-027-000
 
Vocational Services Closing Cover Sheet

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.



Form
F252-028-000
 
Sample Self-Employment Agreement

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.



Form
F252-032-000
 
Employer's Job Description

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.



Form
F252-040-000
 
Sample Format for Vocational Testing Report

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



Form
F252-051-000
 
Sample Format for Vocational Evaluation Testing Plan

Used by vocational counselors to evaluate the testing plan of the injuried worker.



Form
F252-052-000
 
Industrial Insurance Discrimination Complaint
Employees who believe they have been discriminated against by their employer use this form to file a complaint.

Form
F262-009-000

Alt Language(s):
Español
 
Queja por Discriminación

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



Form
F262-009-999

Alt Language(s):
Inglés
 
Occupational Disease Employment History Hearing Loss
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. F262-013-111 is the continuation sheet.

Form
F262-013-000

Alt Language(s):
Español
 
Occupational Disease Employment History Hearing Loss (Continuation)
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.

Form
F262-013-111

Alt Language(s):
Español
 
Occupational Hearing Loss Questionnaire
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.

Form
F262-016-000

Alt Language(s):
Español
 
Cuestionario Sobre la Pérdida del Sentido Auditivo en el Trabajo

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.



Form
F262-016-999

Alt Language(s):
Inglés
 
Intent to Hire Preferred Worker
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.

Form
F280-010-000
 
Intent to Hire Preferred Worker with Developmental Disabilities
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.

Form
F280-011-000
 
Preferred Worker Employers Job Decsription
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.

Form
F280-022-000
 
Request for Preferred Workers Status

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



Form
F280-023-000
 
Chemical Hazard Communication: Helpful information for employers
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.

Publication
F413-012-000

Alt Language(s):
中国的
한국의
Español
Việt
 
Your Body, Your Job: Preventing Carpal Tunnel Syndrome and Other Upper Extremity Musculoskeletal Disorders
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.

Publication
F413-024-000

Alt Language(s):
Español
 
Su cuerpo, su empleo: Prevención del Síndrome del Túnel Carpiano y otras lesiones músculo esqueléticas...

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.



Publication
F413-024-999

Alt Language(s):
Inglés
 
Asbestos Abatement Project Notice of Intent and L&I DOSH Asbestos Program

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.



Form
F413-025-000
 
Working Safely with Asbestos in Brake and Clutch Linings
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.

Poster
F413-049-000
 
Cholinesterase Blood Testing Choice

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



Form
F413-064-000

Alt Language(s):
Español
Español
 
Elección para Prueba de Sangre de Colinesterasa

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



Form
F413-064-999

Alt Language(s):
Inglés
Inglés
 
Variance Application - IND S&H

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.



Form
F414-021-000
 
Workplace Safety and Health Rules and Guides

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.



CD
F414-074-034
 
Safety and Health Discrimination Complaint

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



Form
F416-011-000

Alt Language(s):
Español
 
Safety and Health Discriminaiton Complaint - (Spanish) Queja de Discriminación de la División de Seguridad Y Salud Ocupacional

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.



Form
F416-011-999

Alt Language(s):
Inglés
 
Statement

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.



Form
F416-016-000
 
Application for Charter Boat Operators License

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



Form
F416-034-000
 
Physical Exam - Charter Boat Operators License

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



Form
F416-056-000
 
Job Safety and Health Law - Spanish Ley de Seguridad y Salud en el Trabajo (English/Spanish)

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.

Please order from L&I or print on 11" x 17" paper.

Get poster printing tips.



Poster
F416-081-909
 
Application for Permit to Operate Radio System in Designated Area

This form is used by the logging industry to apply for a permit to operate a radio signal system. What you type in the top form appears in the bottom one, so you have a copy.



Form
F416-087-000
 
A Guide to Workplace Safety and Health in Washington State

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



Publication
F416-132-000

Alt Language(s):
Español
 
Logging Emergency Medical Plan (Logging Safety and Health Meetings)

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



Form
F417-014-000
 
Supervisor's Report of an Accident

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



Form
F417-048-000
 
Quick Tips for Lifting/Consejos Breves para Levantar Cargas (English/Spanish)

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



Publication
F417-055-909
 
Competent Person Evaluation - Fall Restraint & Fall Arrest

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 standard.



Form
F417-102-000
 
Competent Person Evaluation - Excavation & Trenching

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.



Form
F417-104-000
 
Fall Protection Work Plan Requirements

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



Form
F417-107-000
 
Lessons for Lifting & Moving Materials
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.

Publication
F417-129-000
 
Office Ergonomics: Practical solutions for a safer workplace
Book: Provides information and tools to analyze office jobs, find problems and develop ergonomic solutions.

Publication
F417-133-000
 
Workplace Violence: Awareness and Prevention for Employers and Employees
Book: Describes four types of workplace violence, outlines steps to minimize and prevent violent acts, and discusses potential risk factors and prevention techniques.

Publication
F417-140-000
 
Safety and Health Discrimination in the Workplace (English/Spanish)/ Discriminación de seguridad y salud en el lugar de trabajo

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.



Poster
F417-188-909
 
Lumber Handling in Sawmills

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.



Manual
F417-196-000
 
Reservation Form Safety and Health Video Library

Use this form to make reservations of safety and health videos. There is both a fillable MS Word form that you can email in, and a fillable PDF that you can fill and print.



Form
F417-206-000
 
Personal Protective Equipment (PPE) Guide
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.

Publication
F417-207-000
 
Fall Protection: Responding to Emergencies
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.

Publication
F417-208-000
 
Keep Your Employees Safe and Working

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.



Publication
F417-209-000

Alt Language(s):
Español
 
Keep Your Employees Safe and Working - Spanish (Mantenga a sus empleados seguros y trabajando)

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.



Publication
F417-209-999

Alt Language(s):
Inglés
 
Jorge's New Job: Cholinesterase Testing in Washington State - Spanish Un Nuevo Trabajo para Jorge(English/Spanish)

Pamphlet/booklet: Uses a story format with dialogue and photographs to explain the hazards of cholinesterase-inhibiting pesticides, the state's monitoring program and the importance of using proper safety equipment when working with pesticides.



Publication
F417-213-909
 
Protect Yourself and Your Family from Lead Poisoning
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.

Publication
F417-214-000
 
Application for Copies of Citation and Notice

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



Form
F418-023-000
 
Alleged Safety Or Health Hazards (DOSH Complaint Form)

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



Form
F418-052-000

Alt Language(s):
Español
 
Alleged Safety Or Health Hazards (DOSH Complaint Form) Spanish - Presuntos Riesgos de Salud y Seguridad (Formulario de Queja de DOSH)

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



Form
F418-052-999

Alt Language(s):
Inglés
 
Application for Amusement Ride or Air Supported Structure Operating Permit

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



Form
F500-010-000
 
Application for Electrical Contractors License

Application used to get an electrical contractors license



Form
F500-018-000
 
Electrical/Telecommunications Contractor's Bond to the State of WA
Used to show proof of a bond in the State of Washington.

Form
F500-019-000
 
Electrical/Telecommunications Contractor Assignment of Savings Account
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.

Form
F500-020-000
 
Request for Duplicate or Replacement License or Certificate

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



Form
F500-032-000
 
Affidavit of Experience

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.



Form
F500-043-000
 
Request for Change of Address

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



Form
F500-044-000
 
Administrator / Electrician / Master Electrician Certificate Renewal

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



Form
F500-045-000
 
Application to Establish an Account and Access to L&I's Electrical Permit & Inspection System (EPIS) with L&I's Miscellaneous Accounts
To request access to L&I's EPIS - Miscellaneous Accounts

Form
F500-054-000
 
Electrical Installation Variance Application

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.



Form
F500-063-000
 
Application for Amusement Ride Inspector Certification

Application to be certified as an amusement ride inspector.



Form
F500-065-000
 
Affidavit for Amusement Rides
Affidavit of experience to apply for cetification as a Amusement Ride Inspector.

Form
F500-066-000
 
Electrical Education Course Application

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.



Form
F500-068-000
 
Reassignment of Savings Account or Time Deposit - Electrical Contractor

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.



Form
F500-072-000
 
Investigation Report
To notify L&I on any electrical work that you think is illegal.

Form
F500-076-000
 
Electrical / Telecommunication Contractor's License Renewal Notice

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



Form
F500-077-000
 
Account Deposit for Contractor's or Miscellaneous Account Holder's

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



Form
F500-080-000
 
Electrical Inspection Witness Statement
Used to gather information from a person who was a witness to electrical work that is being investigated by L&I.

Form
F500-087-000
 
Application for Master Electrician Certification Examination

Use this form to apply for the master electrician exam.



Form
F500-088-000
 
Electrical Continuing Education Instructor Application

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



Form
F500-090-000
 
Contractor Electrical Work Permit Application

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



Form
F500-093-000
 
Property Owner Electrical Work Permit Application

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



Form
F500-094-000
 
Application for Telecommunications Contractor's License

Application used to get an telecommunications contractors license.



Form
F503-008-000
 
Change Assignment of Administrator/Master Certificate

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



Form
F503-009-000
 
Non-Compliance Report - Boiler & Pressure Vessel Inspection
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.

Form
F620-012-000
 
Shop and Field Inspection Report
Used by L&I inspectors when they inspect boilers.

Form
F620-027-000
 
Boiler / Pressure Vessel Water Heater Installation or Reinstallation Permit
This form is filled out by the installer, contractor and/or owner who wants to install or reinstall a boiler.

Form
F620-032-000
 
Application for Certificate of Competency as an Inspector of Pressure Retaining Items
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. Emailed 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.

Form
F620-040-000
 
Boiler/Pressure Vessel Clearance Variance Request
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.

Form
F620-041-000
 
Rental Boiler Operating Permit - Good at this Location Only
To request a permit to use a rental boiler at one location only.

Form
F620-042-000
 
Historical Boilers Inspection Guideline
Inspection sheet for boiler inspectors. 4 pages.

Form
F620-043-000
 
Incident Report Boiler or Pressure Vessel
Used for the reporting of incident with boilers or a pressure vessels.

Form
F620-044-000
 
Elevator Installation Variance Application

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



Form
F621-048-000
 
Elevator Information Update

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



Form
F621-050-000
 
Elevator Five-Year Safety Test Report

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



Form
F621-051-000
 
Hydraulic Overpressure Test

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



Form
F621-052-000
 
Extension Request

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



Form
F621-053-000
 
Test of Escalator Safety Devices

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



Form
F621-055-000
 
Conveyance Installation Approval by Building Official

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



Form
F621-056-000
 
New Elevator Installation Checklist

Checklist for the elevator company/contractor to complete before the call L&I for an elevator inspection. Includes DEc 2010 letter on ASME checklists.



Form
F621-057-000
 
Owner Requested Red Tag Form

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



Form
F621-063-000
 
Request for Duplicate Elevator Certificate

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



Form
F621-065-000
 
Application for Licensure as an Elevator Mechanic

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.



Form
F621-067-000
 
Temporary Licensed Elevator Mechanic

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



Form
F621-068-000
 
Licensed Elevator Contractor (LC) Operation

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.



Form
F621-069-000
 
License Requirements for Elevator Mechanics and Contractors
Fact sheet: Explains licensing and testing requirements for mechanics who work on elevators and for contractors who install, repair or maintain elevators.

Publication
F621-070-000
 
Elevator Continuing Education Course Application

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



Form
F621-077-000
 
Elevator Continuing Education Instructor Application

Application to become an instructor for elevator related courses.



Form
F621-078-000
 
Plan Approval Request - Recreational Vehicles and Recreational Park Trailers

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



Form
F622-006-000
 
Alteration Fire Safety Pre-Inspection Checklist

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



Form
F622-011-000

Alt Language(s):
Español
 
Alteration Fire Safety Pre-Inspection Checklist -Spanish Lista de Comprobación para la Preinspección de Seguridad contra Incendios

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



Form
F622-011-999

Alt Language(s):
Inglés
 
Electric / Gas Conversion Pre-Inspection Checklist

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.



Form
F622-013-000
 
Air Conditioner/Heat Pump Pre-Inspection Checklist

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



Form
F622-014-000
 
Wood / Pellet Stove / Fireplace Pre-Inspection Checklist

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



Form
F622-015-000
 
Application for State Plan Insignia for Recreational Vehicles and Recreational Park Trailers

To apply for an insignia for a recreational vehicle.



Form
F622-021-000
 
Insignia Continuation Sheet Recreational Vehicles and Park Trailers

Continuation sheet to apply for an insignia.



Form
F622-021-111
 
Plan Approval Request - Conversion Vendor / Medical Units

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



Form
F622-035-000
 
Low Voltage Fire / Intrusion Alarm Checklist

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



Form
F622-038-000
 
Alteration Re-Roofing for Low Slope Roofing

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



Form
F622-039-000
 
Flood Damaged Manufactured Home Checklist

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.



Form
F622-040-000
 
Is it a Manufactured / Mobile Home?

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.



Form
F622-043-000
 
Steel or Wrought-Iron Gas Line Pre-Inspection Checklist

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.



Form
F622-044-000
 
Gas Room Heaters Pre-Inspection Checklist

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.



Form
F622-045-000
 
Copper Tubing Gas Line Pre-Inspection Checklist

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
F622-046-000
 
Gas Piping Test Affidavit

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.



Form
F622-048-000
 
Your Manufactured / Mobile Home
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.

Publication
F622-049-000

Alt Language(s):
Español
 
Alteration Polybutylene Re-Pipe Pre-Inspection Checklist

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.



Form
F622-053-000
 
Homeowners Manufactured / Mobile Home Variance Request

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



Form
F622-054-000
 
Decertification of Manufactured and Mobile Homes

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



Form
F622-063-000
 
Plan Approval Request - Factory Built Structures and Commercial Coaches

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



Form
F623-006-000
 
Notification to Local Enforcement Agency

L&I sends this form to notify the local agencies when a factory-built structure is being shipped within a county or city limits.



Form
F623-013-000
 
Application for Insignia for Factory Assembled Structures

Manufacturers uses this form to apply for an official insignia for a factory-built structure that has a plan approval number.



Form
F623-014-000
 
Application for Insignia for Commercial Coaches

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



Form
F623-019-000
 
Application for Insignia Conversion Vendor/Medical Units

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.



Form
F623-021-000
 
Application for Construction Contractor Registration

This is the form you would complete to register as a construction contractor.



Form
F625-001-000
 
Facts About Construction Liens
Fact sheet: Explains the basics of the construction lien law to help consumers protect themselves.

Publication
F625-017-000
 
Waiver of Lien by Contractor, Subcontractor(s) and Supplier

This is a waiver of lien by a contractor or a subcontractor or supplier.



Form
F625-029-000
 
Model Disclosure Statement Notice to Customer

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.



Form
F625-030-000
 
Contractor Complaint Form

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



Form
F625-033-000
 
Construction Contractors: Get the Facts, Get Registered
Pamphlet/booklet: Explains the steps to register as a construction contractor in Washington State.

Publication
F625-040-000

Alt Language(s):
Español
 
Subscription Request for Construction Contractor and Electrical Basic - CD

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



Form
F625-051-000
 
Filing Suit Against an Electrical Contractor

Instructions for filing suit against an electrical contractor



Form
F625-053-000
 
Construction Lien Notice

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.



Form
F625-054-000
 
Construction Lien Summary

General requirements that a lien claimant of a private construction project (not a commercial) must meet. This is intended show the general requirements for most lien claimants.



Form
F625-055-000
 
Contractor Financial Information

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



Form
F625-061-000
 
Affidavit to Release Public Records

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



Form
F625-066-000
 
What You Should Know About Hiring a Contractor, Remodeler, or Handyman

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.



Publication
F625-084-000

Alt Language(s):
Español
 
What to Do if You Want to File Suit Against Your Construction Contractor

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.



Publication
F625-088-000
 
Request for Archive Records - Contractor Registration

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



Form
F625-094-000
 
Contractors: What if You Get a Notice of Infraction?

Pamphlet/booklet: Tells contractors what their options are and what to do if they get a Notice of Infraction (a non-criminal violation). This publication currently unavailable due to revisions in progress. Check back for updates.



Publication
F625-097-000
 
Application for Electrician Examination

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



Form
F626-001-000
 
Application / Renewal for an Electrical Training Certificate

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



Form
F626-048-000
 
Application for Plumber Trainee Certificate

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



Form
F627-003-000
 
Affidavit of Experience - Plumbers

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



Form
F627-004-000
 
Application for Plumber Examination, Reciprocal, Medical Gas Endorsement, or Temporary Permit

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



Form
F627-008-000
 
Request for Duplicate or Replacement Certificate

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



Form
F627-014-000
 
Plumber, Medical Gas, or Trainee Renewal

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



Form
F627-019-000
 
Facts about State Certification for Plumbers
Fact sheet: Explains plumber classifications, certification requirements, including required exams, and the application and renewal processes, including continuing education requirements.

Publication
F627-022-000
 
Facts about Medical Gas Piping Installer Endorsement
Fact sheet: Explains training requirements and the endorsement process for medical gas piping installers.

Publication
F627-026-000
 
Plumbers Examination Dates and Locations

The 2014 Plumber Examination Dates and Locations. A printed version is also available from the L&I Warehouse.



Form
F627-027-000
 
Application for Backflow Trainee Certificate

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



Form
F627-033-000
 
Application for Backflow Specialty Exam

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



Form
F627-035-000
 
Plumber Continuing Education Course Application

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



Form
F627-037-000
 
Parent / School Authorization for Employment of a Minor and Special Variance

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.

For hiring youth only during non-school weeks, you may use form F700-168-000 Parent Authorization Summer Work  



Form
F700-002-000
 
Affidavit of Wages Paid - Public Works Contract and Instructions

This form is a fillable Word document that is used by a contractor, company or agency to show the wages paid to employees on a public works project. The best way to use this document is to bookmark this page as a “Favorite” in your web browser. Then each time when you want to use the document, access the online version of the form. This will ensure you are always utilizing the most recently published form. (We recommend you not download the document and save the form for future use because we may make changes to the form that your downloaded version will not contain.) You must file the Affidavit of Wages Paid form when you have completed your portion of a public works job/project. Addendum A is form number F700-161-000, Addendum C is form number F700-162-000, and the EHB 2805 (RCW 39.04.370) Addendum is form number F700-164-000.



Form
F700-007-000
 
Record Keeping Provisions - Employment Standards

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



Form
F700-009-000
 
Application for Farm Labor Contractor License

Used to apply or renew a license.



Form
F700-014-000
 
Teens at Work: Facts for Employers, Parents and Teens

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.



Publication
F700-022-000

Alt Language(s):
Español
 
Wage Transcription and Computation Sheet

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



Form
F700-024-000
 
Prevailing Wage Complaint and Instructions

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.



Form
F700-146-000

Alt Language(s):
Español
 
Prevailing Wage Complaint Instructions - Spanish - Instrucciones para el Registro de una Queja Sobre Salario Prevaleciente

Ask L&I to conduct an investigation into a prevailing wage-related issue that affects one or more employees.



Form
F700-146-999

Alt Language(s):
Inglés
 
Statement of Intent to Pay Prevailing Wages - Public Works Contract

This form is a fillable Word document that is used by a contractor, company or agency upon accepting work on a public works project. The best way to use this use this document is to bookmark this page as a “Favorite” in your web browser. Then each time when you want to use the document, access the online version of the form. This will ensure you are always utilizing the most recently published form. (We recommend you not download the document and save it for future use because we may make changes to the form that your downloaded version will not contain.) You should file this form immediately after the contract is awarded and before you begin work. Form number F700-160-000 is addendum A and F700-163-000 is addendum C.



Form
F700-029-000
 
Agreement - Farm Labor Contractors and Workers

Employment wages and conditions agreement with Farm Labor Contractors and Workers



Form
F700-046-000

Alt Language(s):
Español
 
Agreement - Farm Labor Contractors and Workers - Spanish - Acuerdo entre Contratistas Agrícolas y Trabajadores

Employment wages and conditions agreement with Farm Labor Contractors and Workers



Form
F700-046-999

Alt Language(s):
Inglés
 
Farm Labor Contractor Assignment of Account or Time Deposit

Farm Labor Contractor assignment of account or tme deposit for employee



Form
F700-060-000
 
Payment of Wages - RCW 49.48.010 and 49.52.050

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.



Form
F700-064-000
 
Certified Project Payroll

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.



Form
F700-065-000
 
Farm Labor Contractors Bond

Notarized farm labor contractors bond coverage.



Form
F700-066-000
 
What Are Your Rights When You Work for a Farm Labor Contractor? (English/Spanish) / ¿Cúales son sus derechos cuando trabaja para un contratista de trabajadores agrícolas?
Fact sheet: Explains workers' rights when they are employed by a farm labor contractor. Topics covered include workplace safety, rest and meal breaks, and help if injured on the job.

Publication
F700-067-909
 
Your Rights as a Worker in Washington State/ Sus Derechos como Trabajador en el Estado de Washington (English/Spanish)

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.

Please order from L&I or print on 11" x 17" paper.

Get poster printing tips.



Poster
F700-074-909
 
Variance Application - For exceptions from specific rules governing employment of minors.

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



Form
F700-076-000
 
Farm Labor Contractor Registration

Fact Sheet: Explains how to get a farm labor contractor license in order to operate legally as a farm labor contractor in Washington State.



Publication
F700-088-000

Alt Language(s):
Español
 
Variance Application - Employment Standards

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



Form
F700-089-000
 
Young Workers in Agriculture/Trabajadores jóvenes en la agricultura (English/Spanish)

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.



Publication
F700-096-909
 
Internal Revenue Service Tax Compliance Certification

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



Form
F700-098-000
 
Department of Employment Security Tax Compliance Certification

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



Form
F700-099-000
 
Department of Revenue Tax Compliance Certification

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



Form
F700-100-000
 
Your Daily Record of Hours Worked (English/Spanish) / Su Registro de Horas Trabajadas
Pamphlet/booklet: A pocket-sized bilingual booklet to encourage agricultural workers to keep track of their daily work hours and earnings.

Publication
F700-105-909
 
Farm Labor Contractor Complaint Form

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



Form
F700-109-000

Alt Language(s):
Español
 
Formulario de Queja en Contra de un Contratista de Trabajores Agrícolas (Farm Labor Contractor Complaint)

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



Form
F700-109-999

Alt Language(s):
Inglés
 
Farm Labor Contractor Checklist

Farm Labor Contractor's Checklist to ensure compliance.



Form
F700-112-000

Alt Language(s):
Español
 
Employing Children Under Age 14 in Non-Agricultural Jobs

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.



Publication
F700-117-000
 
Employer Petition to The Court for Minor Work Permit Under Age 14

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



Form
F700-118-000
 
Court Form Granting Permission for Employment of Minors

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



Form
F700-119-000
 
Application for Special Certificate to Employ at A Subminimum Wage Rate

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



Form
F700-120-000
 
Application for Special Certificate to Employ A Vocationally Handicapped Worker at at Subprevailing Wage Rate

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



Form
F700-122-000
 
Application to Reopen Crime Victim Claim Due to Worsening of Condition

Benefits are limited to $50,000 per claim. if your claim has met or exceeded this cap, your reopening application will be denied and we will be unable to pay any further benefits. Used by victims of crime and medical or mental health providers to request a claim be reopened.



Form
F800-031-000

Alt Language(s):
Español
 
Application for Benefits - Crime Victims

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. The Spanish version of the instructions are online as F800-042-999.



Form
F800-042-000

Alt Language(s):
Español
 
Application for Benefits- Crime Victims Spanish - Instrucciones para: Solicitud para Beneficios para Víctimas de Crimen

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. This 12-10 version is internet only.



Form
F800-042-999

Alt Language(s):
Inglés
 
Request for Survivor Counseling Benefits (English/Spanish) Solicitud para Beneficios de Apoyo para los Sobrevivientes  

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



Form
F800-057-909
 
Crime Victims Statement for Pharmacy Services

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



Form
F800-058-000
 
Crime Victims Provider's Request for Adjustment

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.



Form
F800-064-000
 
Statewide Payee Registration and W-9 Form Crime Victims

Used by a provider assisting victims of crime to obtain a taxpayer ID number. Note: Register now for direct deposit available January 2013.



Form
F800-065-000
 
Crime Victims Statement for 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.



Form
F800-070-000
 
Know What to Expect: How Recoveries and Settlements May Impact Your Crime Victim Claim

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.



Publication
F800-074-000
 
Statement for Crime Victim Miscellaneous Services

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.



Form
F800-076-000
 
Crime Victims Compensation Program Initial Response and Assessment: Form I
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).

Form
F800-080-000
 
Crime Victims Compensation Program Initial Response and Assessment: Form II

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)



Form
F800-081-000
 
Crime Victims Compensation Program Progress Note: Form III

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



Form
F800-082-000
 
Crime Victims Compensation Program Treatment Report: Form IV

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



Form
F800-083-000
 
Safety Comes Thru Job Training
A supervisor having a discussion with his crew. Get poster printing tips.

Poster
FSP0-901-000
 
Poster - An Unprotected Trench is an Early Grave

Poster: Trench safety information for employers. Features tips to prevent cave-ins, and proper inspection proceedures. Get poster printing tips.



Poster
FSP0-912-000
 
Caution: Hard Hat Area
Visual reminder of the importance of wearing a hard hat. Get poster printing tips.

Poster
FSP0-928-000

Alt Language(s):
Español
 
Precaución: Obligatorio Usar Casco
Picture of hard hats. Get poster printing tips.

Poster
FSP0-928-999

Alt Language(s):
Inglés
 
Siempre Use Protección para los ojos
Picture of a large eye with some content on when to use eye protection. Get poster printing tips.

Poster
FSP0-940-999

Alt Language(s):
Inglés
 
Always Wear Eye Protection

Sticker: 7.25 inches X 4.25 inches.



Sticker
FSP0-941-000
 
Danger! Minimum Clearance for Counter Balance - Construction

Sticker: 30 inches long.



Sticker
FSP0-974-000
 
Put this Guard Back - 8.5 x 3.5 inches

Sticker: 8.5 inches X 3.5 inches



Sticker
FSP0-993-000

Alt Language(s):
Español
 
Put this Guard Back - 5 1/2 x 2 1/8 inches

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



Sticker
FSP0-993-001

Alt Language(s):
Español
 
 Si usted TIENE que remover este resguardo 8.5 x 5.5

Sticker: 8.5 inches X 3.5 inches



Sticker
FSP0-993-999

Alt Language(s):
Inglés
 
Grinding Wheel - Prevent Accidents

Sticker size 4"x3"



Sticker
FSP1-000-000
 
Report All Injuries Promptly
Large words: Report All Injuries Promptly. Get poster printing tips.

Poster
FSP1-004-000

Alt Language(s):
Español
 
Reporte Todas las Lesiones Inmediatamente

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



Poster
FSP1-004-999

Alt Language(s):
Inglés
 
First Aid

Safety Sticker size 5"x6"



Sticker
FSP1-005-000
 
Danger, Workers Above
Picture of workers on a high rise. Get poster printing tips.

Poster
FSP1-012-000

Alt Language(s):
Español
 
Danger, Workers Above-Spanish (Peligro - Trabajadores en el Nivel Superior)

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



Poster
FSP1-012-999

Alt Language(s):
Inglés
 
Danger, Construction Area Authorized Personnel Only
Large words: Danger, Construction Area Authorized Personnel Only. Get poster printing tips.

Poster
FSP1-013-000

Alt Language(s):
Español
 
Peligro - Área en Construcción - Solamente Personas Authorizadas

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



Poster
FSP1-013-999

Alt Language(s):
Inglés
 
Danger
Large lettering: DANGER. Get poster printing tips.

Poster
FSP1-030-000

Alt Language(s):
Español
 
Cartel - PELIGRO

Large lettering: PELIGRO



Poster
FSP1-030-999

Alt Language(s):
Inglés
 
Know Your Lockout Tagout Safety Procedures
Poster: Visual reminder you can print for posting in appropriate workplaces. Two options available for download and/or printing.

Poster
FSP1-063-000
 
Self-Insured Employers' Medical Only Claim Closure Order and Notice

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.



Form
F207-020-111

Alt Language(s):
Español
 
Notificación de Decisión de Cierre para Reclamos Únicamente Médicos para Empleadores Autoasegurados

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.



Form
F207-020-999

Alt Language(s):
Inglés
 
Notificación de Decisión de Cierre para reclamos de Tiempo Perdido para Empleadores Autoasegurados

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.



Form
F207-070-999

Alt Language(s):
Inglés
 
Renewal of Elevator Mechanic License

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



Form
F621-080-000
 
Request for Duplicate Elevator Mechanic License

Request for Duplicate Elevator Mechanic License



Form
F621-099-000
 
Elevator Mechanic and Elevator Temporary Mechanic Address/Mailing Information Update

Elevator Mechanic and Elevator Temporary Mechanic Address/Mailing Information Update



Form
F621-100-000
 
Notificación de Decisión de Cierre con Discapacidad Parcial Permanente para Empleadores Autoasegurados - PPD-TL

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.



Form
F207-164-999

Alt Language(s):
Inglés
 
Notificación de Decisión de Cierre con Discapacidad Parcial Permanente para Empleadores Autoasegurados - PPD-NTL

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.



Form
F207-165-999

Alt Language(s):
Inglés
 





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