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Self-Insurance Report of Occupational Injury or Disease (SIF-5)

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



Form
F207-005-000
 
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
 
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
 
Assignment of Account or Time Deposit for Insurance - Bodily Injury - WA State Banks Only

Contractors may use this form to request an Assignment of Account in lieu of an insurance policy for bodily injury. The amount of the insurance policy would need to be placed into an account at a WA State Bank.



Form
F625-082-000
 
Notice to Attending Physician of Apprentice / On-the-Job-Training Accident / Incident

A notice to the attending physician that the individual is a Registered Apprentice and to attach this form to the Accident Report of Industry Injury or Occupational Disease (F242-130-000).



Form
F100-511-000
 
Need a Doctor?
Information card: Provides contact information for injured workers needing assistance in finding a health-care provider who will treat their occupational injury or disease. This PDF will print out an 8.5" X 11" sheet that has 12 copies of the card. Note: Disclaimer information on Page 2 may not line up accurately in two-sided printing.

Publication
F160-006-000

Alt Language(s):
Español
 
Need a Doctor? - Spanish (¿Necesita un doctor?)
Information card: Provides contact information for injured workers needing assistance in finding a health-care provider who will treat their occupational injury or disease. This PDF will print out an 8.5" X 11" sheet that has 12 copies of the card. Note: Disclaimer information on Page 2 may not line up accurately in two-sided printing.

Publication
F160-006-999

Alt Language(s):
Inglés
 
Self-Insurer Accident Report (SIF-2)

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



Form
F207-002-000
 
Provider's Initial Report (PIR)

Used by medical providers when reporting initial treatment for an industrial injury or occupational disease for a self-insured claim. The paper version dated 10-2012 is still valid, as is the 01-2014 word fillable version.

Medical providers treating self-insured workers, self-insured businesses, or their third party claims administrators can access this form one of two ways:

  1. Download the Microsoft (MS) Word form and the PDF file with instructions:

           The first file is the PDF instructions.

           The second file is an Office 2003 MSWord document ending in .doc.

           The third file is an Office 2007/2010 version, ending in .docx.

2.  Order paper copies of this form by clicking the “order it” button.



Form
F207-028-000
 
Notice to Employees -- Self-Insurance/Aviso a los Empleados -- Seguro Industrial Propio (English/Spanish)

Required poster for self-insured businesses: Outlines what a worker employed by a self-insured business should do if a work-related injury or illness occurs. Note: Self-insured employers must display this poster where workers can see it.



Poster
F207-037-909
 
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
 
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
 
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
 
Application to Reopen Claim due to Worsening Condition - Spanish APLICACIÓN PARA REABRIR UN RECLAMO

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.



Form
F242-079-909

Alt Language(s):
Inglés
Español
 
Application to Reopen Claim due to Worsening Condition - Spanish Aplicación para Reabrir un Reclamo Debido al Empeoramiento de la Condición 

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.



Form
F242-079-999

Alt Language(s):
Inglés
English/Español
 
Workers' Compensation Benefits: A Guide for Injured Workers

Pamphlet/booklet: For workers covered by L&I (the State Fund). Describes benefits if you have a work-related injury or illness and how to file a claim. Explains a worker's rights and responsibilities under Washington State's industrial insurance law. Note: Previously titled, Workers' Guide to Industrial Insurance Benefits.



Publication
F242-104-000

Alt Language(s):
Español
 
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 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
 
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 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
 
Affidavit for Time Loss Compensation Benefits

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.



Form
F242-395-000

Alt Language(s):
Español
 
Affidavit_for_Time_Loss_Compensation_Benefits (Spanish) Declaración Firmada para Compensación de Tiempo Perdido

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.



Form
F242-395-999

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

Publication
F242-398-000
 
FileFast poster for workers
Poster (8.5 x 11): Explains to workers why and how to file an accident report online or by phone following an injury and reminds them to stay in contact with employer and L&I.

Poster
F242-399-000
 
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
 
Chronic Opioid Request Form

Use this form to request opioid coverage beyond 12 weeks from the date of injury or surgery, or every 90 days for chronic opioid therapy.



Form
F252-091-000
 
Subacute Opioid Request Form

Use this form to request opioid coverage between 6 weeks to 12 weeks from the date of injury or surgery.



Form
F252-097-000
 
Claim Suppression Complaint

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



Form
F262-024-000

Alt Language(s):
Español
 
Queja por Suprimir un Reclamo - Spanish - Claim Suppression Complaint
An injured worker may submit this form if their employer has suppressed their right to file an injury claim.

Form
F262-024-999

Alt Language(s):
Inglés
 
Workers' Compensation Discrimination-English/Spanish (Discriminación porque se lesionó en su trabajo)
Fact sheet: Explains workers' legal right to file a workplace injury claim and how to file a complaint if discrimination has occurred.

Publication
F262-249-909
 
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 Program

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.



Publication
F280-021-000

Alt Language(s):
Español
 
Preferred Worker Program-Spanish (Programa con Incentivos para Reemplear Trabajadores Lesionados)

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.



Publication
F280-021-999

Alt Language(s):
Inglés
 
Supervisor's Report of an Accident

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



Form
F417-048-000
 
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
 
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
 
Ergonomics Consultation: Free, Confidential, Powerful Impact on Your Bottom Line

Pamphlet: Provides information to employers interested in a free ergonomics consultation for their business. Explains the importance of workplace ergonomics and how L&I can help to assess injury-causing tasks, and help develop an ergonomics program.



Publication
F417-233-000
 
When a Loved One Dies at Work

Brochure: Provides information to loved ones of workers who died from a job-related injury or illness, including how to apply for survivor benefits. Explains the L&I fatality investigation and how family members can stay informed of the investigation's status.



Publication
F417-240-000

Alt Language(s):
Español
 
When a Loved One Dies at Work - Spanish (Cuando un ser querido fallece en el lugar de trabajo)

Brochure: Provides information to loved ones of workers who died from a job-related injury or illness, including how to apply for survivor benefits. Explains the L&I fatality investigation and how family members can stay informed of the investigation's status.



Publication
F417-240-999

Alt Language(s):
Inglés
 
Washington State Top 25 Hazardous Industries

Booklet: Provides a summary of occupational injury and illness data, including safety and health violations cited, by the top 25 hazardous industries for the five-year period 2006 to 2010.



Publication
F417-243-000
 
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
 
Instructor's Report of Accident / Incident

This form must be submitted to L&I's Apprenticeship Section by the Instructor at the time of the incident and the appropriate Apprenticeship Program within 5 days of an accident/incident of an apprentice/trainee during Related Supplemental Instruction (RSI).



Form
F100-509-000
 
Getting Back to Work: It's Your Job and Your Future
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.

Publication
F200-001-000

Alt Language(s):
Español
 
Getting Back to Work: It's Your Job and Your Future-Spanish (Regresando a Trabajar es su Trabajo y su Futuro)

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.



Publication
F200-001-999

Alt Language(s):
Inglés
 
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
 
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
 
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
 
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
 
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 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
 
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
 
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
 
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
 
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
 
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
 
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
 
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
 
Hearing Services Worker Information

This is a list of the rights and conditions when an injured worker applies for hearing aids.



Form
F245-049-000
 
Termination of Agreement (Rescission)
To be filled out by the injured worker who wants to return hearing aids.

Form
F245-050-000
 
Employment History Form

Used to provide your employment history for the past three years, including self-employment and volunteer work.

Please start with your most recent job and work backwards. Please list any gaps or interruptions in your work history.  If you were unemployed at any time, please explain why.  Did you apply for (or receive) unemployment benefits during the time period? If yes, what dates did you receive unemployment benefits?  Did you seek employment during the time period?  If no, why didn’t you seek employment?



Form
F242-109-000

Alt Language(s):
Español
 
Employment History Form Spanish Formulario de Historial de Empleo

Used by injured worker to report their employment history for the past three years and the wages at each job.



Form
F242-109-999

Alt Language(s):
Inglés
 
Physical Therapy / Occupational Therapy Progress Report to Claim Managers

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



Form
F245-059-000
 
Frequently Asked Questions about Job Modifications
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.

Publication
F245-057-000
 
¿Lesionado por un tercero? Usted tiene opciones legales - English (Injured by a Third Party? You Have Legal Options)
Folleto: Un resumen de los derechos legales y opciones que tiene un trabajador lesionado si una acción contra un tercero está relacionada con su reclamo de compensación para los trabajadores. Incluye el Formulario de elección contra terceros que debe ser completado por el trabajador. Aviso. El formulario debe imprimirse, firmarse y enviarse por correo.

Form
F249-008-999

Alt Language(s):
Inglés
 
SIF-4 Self Insured Employer's Request for Denial of 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.

Form
F207-163-000
 
Protegiendo a los trabajadores de Washington (Protecting Washington Workers)
DVD: An innovative tool to teach Spanish-speaking workers about workplace rights while introducing English terminology.

DVD
F130-004-909
 
Making the Best Treatment Choice for Your Chronic Low-back Pain
Fact sheet: Reviews the options that an injured worker with low-back pain should consider in determining the best treatment choice.

Publication
F252-081-000
 
Making the Best Treatment Choice for Your Chronic Low-back Pain-Spanish (Cómo Hacer la Mejor Elección de Tratamiento para el Dolor Crónico en la Parte Inferior de su Espalda)

Fact sheet: Reviews the options that an injured worker with low-back pain should consider in determining the best treatment choice.



Publication
F252-081-999

Alt Language(s):
Inglés
 
Pension and Survivor Benefits in Washington State's Workers' Compensation Program--English/Spanish (Beneficios de Pensión y para Sobrevivientes del Programa de Compensacin para Trabajadores de Washington)

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



Publication
F242-352-909
 
Stay at Work Wage Reimbursement Application for Employers

Employer of record can request reimbursement for wages paid to an injured worker during light duty or transitional work. After completing the form, the employer submits it, along with supporting documentation, to the Stay at Work program for review and approval. For expense reimbursements see F243-003-000.



Form
F243-001-000
 
Stay at Work Expense Reimbursement Application for Employers Tools, Clothing, Training.

Employer of record can request reimbursement for tools, clothing, or training expenses required to enable an injured worker to return to light duty or transitional work. After completing the form, the employer submits it, along with supporting documentation, to the Stay at Work program for review and approval. For wage reimbursements see F243-001-000.



Form
F243-003-000
 
Workplace Safety and Health Pocket Guide

Pocket guide: Provides links to online information, including safety and health consultations, how to develop a safety program, reporting hazards and injuries, other safety training, and information for teen workers.



Publication
F417-241-000
 
Occupational Disease Work History - Continuation

This is a continuation page to the Occupational Disease Work History (F242-071-000) to add additional work history.



Form
F242-071-111

Alt Language(s):
Español
 





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