To record the costs for room and board for the first 52 weeks. For use only with plans approved before 1/1/2008. For plans approved after 1/1/2008, use F245-372-000.

To record the work plan time for the first 52 weeks. For use only with plans approved before 1/1/2008. For plans approved after 1/1/2008, use F245-376-000.

Transportation costs for the first 52 weeks. For use only with plans approved before 1/1/2008. For plans approved after 1/1/2008, use F245-375-000.

Pamphlet/booklet: Provides a financial summary of Washington State's workers' compensation system, July 1, 2003 through June 30, 2004.

Pamphlet: Provides a financial summary of Washington State's workers' compensation system, July 1, 2004, through June 30, 2005. Note: This publication was developed before the final data for the 2005 Industrial Insurance SAP Financial report were available. Equity Investments were presented at "cost" in the 2005 Year in Review and later correctly presented at "market" in the 2005 Industrial Insurance SAP Financial Information report.

Pamphlet: Provides a financial summary of Washington State's workers' compensation system, July 1, 2005, through June 30, 2006.

Pamphlet: Provides a financial summary of Washington State's workers' compensation system, July 1, 2006, through June 30, 2007. This is the fourth Year in Review. In addition to the financial summary, it includes claim statistics and information about L&I's fraud prevention results.

Book: Introduces Washington State's Workers' Compensation Program, including rate-setting and investment policies, financial statement overview, and services available to help employers control workers' comp costs.

Pamphlet: Provides a financial summary of Washington State's workers' compensation system, July 1, 2007, through June 30, 2008. This is the fifth Year in Review. In addition to the financial summary, the pamphlet highlights technology improvements for employers, including new features in the online Claim and Account Center.

To record the costs for room and board for the second 52 weeks. For use only with plans approved before 1/1/2008. For plans approved after 1/1/2008, use F245-372-000.

To record the work plan time for the second 52 weeks. For use only with plans approved before 1/1/2008. For plans approved after 1/1/2008, use F245-376-000.

To record the training plan costs for the second 52 weeks. For use only with plans approved before 1/1/2008. For plans approved after 1/1/2008, use F245-374-000.

Transportation costs for the first 52 weeks. For use only with plans approved before 1/1/2008. For plans approved after 1/1/2008, use F245-375-000.

Pamphlet/booklet: Explains to employees of self-insured businesses their rights and responsibilities under industrial insurance law. Describes benefits and how to file a claim.

Pamphlet/booklet: Explains to employees of self-insured businesses their rights and responsibilities under industrial insurance law. Describes benefits and how to file a claim.

This form must be signed by the worker and the VRC and sent in along with the retraining plan to L&I for approval.

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.

Used by the pensioner to notify L&I of a new mailing address. L&I must receive this form by the first day of the month so your monthly payment is received in a timely manner.

Used by certified self-insured companies when they are acquired by another organization. New parent organization guarantees the self-insured workers' compensation liabilities of its new subsidiary.

Used by an employer to apply for self-insurance.

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

Used by self-insured business for their 2008 Annual Report to L&I. This report must be received by L&I by March 1, 2009. Form is dated 1-09, instructions dated 12-08 are attached to the form.

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

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.

Used by employers to apply for workers' compensation coverage for non-mandatory employment. Shows a list of categories of employment that are not considered mandatory to have workers' compensation.

Used 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.

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

Used by organizations that want to form a retrospective rating group, or by established groups to modify their retro plan or maximum premium ratio.

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.

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

Used by a spouse or children to apply for pension survivor benefits if a total permanent disabled worker dies.

Used by a spouse or children to apply for pension survivor benefits if a total permanent disabled worker dies.

Used by employers to apply for self-insurance certification.

Used by self-insured employers to participate in the Orthopedic & Neurological Surgeon Quality Pilot

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

Used by victims of crime and medical or mental health providers to request a claim be reopened. 2-08 version is on the internet, 8-95 version is in the warehouse.

Used by injured workers and doctors to apply to reopen an industrial injury or occupational disease claim that has been closed for longer than 60 days.

Spanish version. Used by injured workers and doctors to apply to reopen an industrial injury or occupational disease claim that has been closed for longer than 60 days.

Used by victims of crime and medical or mental health providers to request a claim be reopened. 2-08 version is on the internet, 8-95 version is in the warehouse.

Booklet: Explains the basics of the assessment phase of vocational services to injured workers. L&I sends this booklet to injured workers when they are referred for assessment services.

Used by only private sector vocational rehabilitation providers to document vocational assessment to determine if a worker is employable based upon transferable skills or needs further vocational services such as retraining.

For use internally by L&I Vocational Service Specialists (VSSs) to determine if all required components are included in the submitted assessment. Can be used by VRCs as a tool. DO NOT SUBMIT TO L&I.

Routing slip that accompanies the Vocational Services Closing Cover Sheet (F252-028-000) which is used to close vocational services to an injured worker only if you are recommending Plan Development. For all other closing reports, use Vocational Closing Report Routing Sheet (F252-027-000).

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

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.

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

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.

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

Used by employers to give authorization to their accountants to submit quarterly reports in their behalf.

Used by the worker to designate a person(s) as an authorized representative for the worker's claim. An authorized representative can access claim information.

Used by the worker to designate a person(s) as an authorized representative for the worker's claim. An authorized representative can access claim information.

Used by an employer to cancel workers' compensation coverage for Sole Proprietors/Partner, Member of Limited Liability Company (LLC), Member of Limited Liability Partnership (LLP) or For-Profit Corporate Officers.

Used by employers to get the categories of employment that are not considered mandatory to have workers' compensation. If they had elected to have coverage this form is used to cancel previously elected coverage of workers' compensation.

Booklet: Explains the basics of the plan implementation phase of vocational services to injured workers. L&I sends this booklet to injured workers once the vocational plan they submitted is approved. Information about continuing with the vocational plan or selecting Option 2 to decline retraining is included.

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

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

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

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

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

Used by surviving spouse or children of a deceased worker to file a claim for benefits.

Used by surviving spouse or children of a deceased worker to file a claim for benefits.

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

Used by the injured worker to provide comments to L&I about their recent medical exam by an IME.

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.

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

Used by employers with no employees or worker hours to report but need an open account for contract bidding process.

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

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.

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.

Quick reference card: Explains the criteria to allow a corporate officer to be exempt from industrial insurance (workers' compensation) coverage.

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

A form used by physicians, hospitals and clinics to provide information and reporting to the Crime Victims Compensation Program.

Used by dependents of a deceased Crime Victim to determine eligibility to receive pension benefits.

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)

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

Used by the clinical provider to inform L&I that you are no longer conducting treatment to the client. This must be submitted within 60 days of the client's last session and you are no longer conducting treatment.

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

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

Used by Spanish speaking dependents of deceased crime victims who are applying for pension benefits.

Used by injured worker who has filed an occupational hearing loss claim to provide more specific information regarding how the hearing loss occurred. This is requested by the Claim Manager and sent to the Injured Worker.

Used by a dependent of a worker whose death was related to an on the job injury or accident. This form must be completed, signed, notarized and returned to L&I within 30 days for non interruption of benefits.

Used by a guardian or other person having custody of the minor or disabled children or dependents of a deceased worker to declare their entitlement to receive the pension benefits for those children/dependents in their care and custody.

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

Used by the widow/widower whose spouse died of a work related injury or accident. This form must be completed, signed, notarized and returned to L&I within 30 days for non interruption of your benefits.

Used by a dependent of a worker whose death was related to an on the job injury or accident. This form must be completed, signed, notarized and returned to L&I within 30 days for non interruption of benefits.

Used by a guardian or other person having custody of the minor or disabled children or dependents of a deceased worker to declare their entitlement to receive the pension benefits for those children/dependents in their care and custody.

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

Used by the widow/widower whose spouse died of a work related injury or accident. This form must be completed, signed, notarized and returned to L&I within 30 days for non interruption of your benefits.

Used by both workers and bidding contractors to read, sign and submit to L&I to verify that they have read, understand and accept their respective responsibilities in the home modification process.

Used by the pensioner to learn about direct deposit. It accompanies the Authorization for Deposit of Payments- Spanish (F242-174-909) form.

Used by the pensioner to learn about direct deposit. It accompanies the Authorization for Deposit of Payments (F242-174-000) form.

Pamphlet: Briefly describes Web pages that contain information of interest to Washington State businesses. Workers' compensation topics include "Quarterly reports--How do I file?" and "Claim-free Discount--Who gets it?" You also will find links to workplace safety rules, sample accident prevention programs, and information about safety grants, plus other information from L&I. Links to other state agency Web sites are included as well.

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

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

Used by employer of record to prepare a written job description for a light duty job, modified duty job, or alternative job when an injured worker is unable to work due to an industrial injury or occupational disease. The form includes a description of the job tasks, machinery, tools, equipment and personal protective equipment used, and the physical demands of the job. After completing the employer's job description form, the employer gives it to the injured worker's doctor for review and approval.

Pamphlet/booklet: Explains the benefits of 'return to work' from the employer's perspective, describes RTW options, and provides resource and contact information.

Book: Explains the basic requirements of Washington's industrial insurance law. Suggests ways to protect workers' safety and health and minimize industrial insurance costs. Includes sample forms and L&I telephone numbers.

Book: Explains the process for employers to provide their own industrial insurance (workers’ compensation) coverage in Washington State. Also reviews surety requirements for self-insurance, reporting and recordkeeping requirements, claims processing, and compliance and legal issues.

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

Quick reference card: Provides a list of employments excluded from workers' compensation coverage, including those eligible for optional coverage.

Completed by the injured worker if they are unable to work due to a workplace injury AND their employer is not paying their full wages.

Fact sheet: Answers questions employers, workers and doctors may have about job modifications, including when to request a job-modification consultant and who pays for the costs involved.

Used by organizations to set up an agreement with L&I authorizing their participation in retrospective rating.

Information card: Introduces the Office of the Ombudsman for Self-Insured Injured Workers. The ombudsman is appointed by the Governor to serve as an independent advocate for the rights of injured workers of self-insured employers.

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

Injuried worker fills out this document to show more work history. This form goes with Occupational Disease & Employment History (F242-071-000).

To record the costs for housing and board. For use only with plans approved after 1/1/2008. For plans approved before 1/1/2008, use form F245-355-000 or F245-358-000.

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

Quick reference card: Provides information to help determine whether a "subcontractor" working for you meets the legal requirements to be an independent contractor, or whether he/she is actually a covered worker for workers' compensation (industrial insurance) purposes.

Used by the injured worker to provide comments to L&I about their recent medical exam by an IME.

Used by employers to set up an agreement between them and L&I authorizing their participation in retrospective rating.

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.

Instructions for completing the Worker's Compensation Employer's Quarterly Report. A sample of the form F212-055-000 is also available on the internet.

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

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.

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.

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

For use by an vocational counselor, employer, etc. to request modification for the injured workers job. This may involve tools and equipment that is purchased through L&I.

Use by a full-time student who is entitled to receive pension benefits. The student must be at least 18 years old and no older than 23 years old. This form is to prove the students intention to register in an accredited school during the next quarter/semester.

Quick reference card: Reviews the requirements for members or managers of limited liability companies to be exempt from workers' compensation (industrial insurance) coverage.

This form has a list of mailing addresses and document types a provider uses to send to L&I. There is also a list of phone numbers.

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

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

Used by an employer to be submitted with the Employer's Quarterly Report for Industrial Insurance as a supplemental reporting form.

Used to order L&I medical forms.

Used by a self-insured employer to signify the employer's obligation and responsibilities in conjunction with providing an annuity as collateral for a total permanent disability claim.

This memorandum of understanding is between a self-insurer and L&I regading the use of an irrevocable standby letter of credit by the self-insurer as surety for its self-insurance obligations.

Used by medical providers to notify L&I that an occupational disease or infection has been diagnosed and that the worker has been advised that their condition may be work-related. This form can be used if the worker does not complete a Report of Accident or Occupational Disease (ROA) but should not be completed in place of an ROA.

Required poster: Outlines the steps a worker should take if a job-related injury or illness occurs. Also briefly describes the benefits available through Washington's workers' compensation system. Note: 'Employers who receive industrial insurance coverage from L&I must display this poster where workers can see it. English and Spanish online versions will print separately. Get poster printing tips.

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. Get poster printing tips.

Used by self-insured employers or their representatives only, this is legal notification to an injured worker that their claim is being closed. This order is used only when time loss compensation has not been paid, but a permanent partial disability award is being paid.

Used by self-insured employers or their representatives only, this is legal notification to an injured worker that their claim is being closed. This order is used only when time loss compensation has been paid, and a permanent partial disability award is also being paid.

Used by self-insured employers or their representatives, this is legal notification to an injured worker that their claim is being closed. This order is used only when time loss compensation has been paid, but no permanent partial disability award is being paid.

Used by self-insured employers or their representatives, this is legal notification to an injured worker that their claim is being closed with medical benefits only. This order is used only when neither time loss compensation nor a permanent partial disability award has been paid.

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

Injuried worker fills out this document to show more work history. This form goes with Occupational Disease & Employment History (F242-071-000).

Used by injured worker who has filed an occupational hearing loss claim to report their employment history and the nature of the noise exposure at each job.

Used by injured worker who has filed an occupational hearing loss claim to report their employment history and the nature of the noise exposure at each job. This form is a continuation of form F262-013-000.

Used by injured worker who has filed an occupational hearing loss claim to provide more specific information regarding how the hearing loss occurred. This is requested by the Claim Manager and sent to the Injured Worker.

Fact sheet: Introduces L&I's new online reporting system for industrial insurance quarterly reports. Explains the differences between Quick File and Deluxe File and compares these two options along with paper filing.

When prescribing opioids for chronic, noncancer pain; the attending physician must submit this form, or an equivalent form at least every 60 days. Providers are encouraged to submit after each visit.

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.

Used by an injured worker who receives an order that states he or she is totally permanently disabled. This questionnaire must be completed in full and all necessary documents attached before his or her pension benefit options can be calculated.

Used by an injured worker who receives an order that states he or she is totally permanently disabled. This questionnaire must be completed in full and all necessary documents attached before his or her pension benefit options can be calculated.

Used by 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.

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

For use internally by L&I Vocational Service Specialists (VSSs) to determine if all required components are included in the submitted plan. Can be used by VRCs as a tool. DO NOT SUBMIT TO L&I.

Routing slip that accompanies the Vocational Services Closing Cover Sheet (F252-028-000) which is used to close vocational services to an injured worker only if you are recommending Plan Approval. For all other closing reports, use Vocational Closing Report Routing Sheet (F252-027-000).

Booklet: Explains the basics of the plan development phase of vocational services to injured workers. L&I sends this booklet to injured workers when they are referred for plan development services. The assigned vocational rehabilitation counselor is required to review this booklet with the worker at their initial face-to-face meeting.

Booklet: Explains the basics of the plan development phase of vocational services to injured workers. L&I send this booklet to injured workers when they are referred for plan development services. The assigned vocational rehabilitation counselor is required to review this booklet with the worker at their initial face-to-face meeting.

To record the work plan time. For use only with plans approved after 1/1/2008. For plans approved before 1/1/2008, use form F245-353-000 or F245-356-000.

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.

Pamphlet/booklet: Helps self-insured employers understand and prepare for an audit.

Providers use to inform L&I that they have changes to their account. Such as changes to their Tax ID address/name, business address, billing address, name, or termination of account. This also includes a W-9 form.

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 used to submit Quarterly Report. If you need a copy of this form to complete your quarterly report, please contact Certification Services at (360) 902-6867.

Used by drywall employers as a guide to completing quarterly and supplemental reports. This includes filled out samples of F212-050-000 and F212-051-000.

Instructions for filling out the quarterly statement of supplemental benefits.

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

Contractors may use this form to request changes to a Assignment of Savings that was filed in lieu of a surety bond or insurance policy.

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

Quick reference card: Identifies the type of records employers, including construction contractors, need to keep to allow L&I to compute premiums.

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).

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.

Used by injured workers, doctors, and employers to report an industrial injury or occupational disease. This report is not available online. Order by the number of copies you need. Do not order by box or case. If you are an injured worker, ask your doctor for a copy of this form.

Used by drywall employers as a guide to completing quarterly and supplemental reports. This includes filled out samples of F212-050-000 and F212-051-000.

Used by employers to teach their employees about the legal requirement to report accidents at work and who to notify if they have an accident at work. After completing the Employee Wallet Card form, the employer gives a wallet card to each employee.

Used by employers to teach their employees about the legal requirement to report accidents at work and who to notify if they have an accident at work. After completing the Employee Wallet Card form, the employer gives a wallet card to each employee.

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

Fillable form to purchase the "State Fund Claims Policy Manual" or the Workers' Compensation Adjudicator (WCA) and Claims Management (CM) Manual set. The costs must be added up manually, then the totals entered in the Total Cost column.

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

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

Used by a provider assisting victims of crime to obtain a taxpayer ID number.

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

Used by department-approved claims administrators to report course completion for obtaining continuing education credit.

Used by sponsors or instructors of continuing education courses, when requesting the department assign credit to a course so that department-approved claims administrators who attend can earn credit toward recertification under the Self Insurance Continuing Education program.

Used by interested parties to register to attend continuing education courses provided by the L&I Self Insurance Section.

Used by employers applying to become self-insured to describe their proposed workers' compensation program.

Used by self-insured employers and third party administrators to enroll for participation in the Self Insurance Electronic Data Reporting System (SIEDRS). F207-197-000 is SIEDRS (Self-Insurance Electronic Data Reporting System) Data Change Request

Book: Explains the technical requirements for participating in SIEDRS, the Self-Insurance Electronic Data Reporting System

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

Used by self-insured employers and their representatives to report to L&I an injured worker's eligibility for vocational services or ability to work. This replaces F207-121-000 Employability Assessment Report (EAR).

Used by self-insured employers, their representatives, and vocational counselors to summarize the outcome of a vocational rehabilitation plan when submitting the closing report.

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

Used by self-insured employers or their representatives, this is legal notification to an injured worker that their claim is being closed with medical benefits only. This order is used only when neither time loss compensation nor a permanent partial disability award has been paid.

Used by self-insured employers or their representatives, this is legal notification to an injured worker that their claim is being closed with medical benefits only. This order is used only when neither time loss compensation nor a permanent partial disability award has been paid.

Used by self-insured employers or their representatives, this is legal notification to an injured worker that their claim is being closed with medical benefits only. This order is used only when neither time loss compensation nor a permanent partial disability award has been paid.

Used by self-insured employers or their representatives only, this is legal notification to an injured worker that their claim is being closed. This order is used only when time loss compensation has not been paid, but a permanent partial disability award is being paid.

Used by self-insured employers or their representatives only, this is legal notification to an injured worker that their claim is being closed. This order is used only when time loss compensation has not been paid, but a permanent partial disability award is being paid.

Used by self-insured employers or their representatives only, this is legal notification to an injured worker that their claim is being closed. This order is used only when time loss compensation has not been paid, but a permanent partial disability award is being paid.

Used by self-insured employers or their representatives only, this is legal notification to an injured worker that their claim is being closed. This order is used only when time loss compensation has been paid, and a permanent partial disability award is also being paid.

Used by self-insured employers or their representatives only, this is legal notification to an injured worker that their claim is being closed. This order is used only when time loss compensation has been paid, and a permanent partial disability award is also being paid.

Used by self-insured employers or their representatives only, this is legal notification to an injured worker that their claim is being closed. This order is used only when time loss compensation has been paid, and a permanent partial disability award is also being paid.

Used by only self-insured employers or their representatives, this is legal notification to an injured worker that their claim is being closed. This order is used only when time loss compensation has been paid, but no permanent partial disability award is being paid.

Used by only self-insured employers or their representatives, this is legal notification to an injured worker that their claim is being closed. This order is used only when time loss compensation has been paid, but no permanent partial disability award is being paid.

Used by only self-insured employers or their representatives, this is legal notification to an injured worker that their claim is being closed. This order is used only when time loss compensation has been paid, but no permanent partial disability award is being paid.

Used to provide collateral for a self-insured program.

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

This is a data change request form. F207-193-000 is the Self-Insurance Electronic Data Reporting System (SIEDRS) Enrollment Form

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

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

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

Used by the pensioner to notify L&I of a new mailing address. L&I must receive this form by the first day of the month so your monthly payment is received in a timely manner.

Used by a self-insured employer to amend or change items on the surety document such as the amount of the escrow agreement used as collateral.

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.

Used for a person who travels as part of their employment with a sports team and that their employment is principally localized in Washington state or another state.

Quick reference card: Provides basic information about standard exception classifications, which can be separately rated from the basic business classification for determining industrial insurance (workers' compensation) premiums.

Completed and signed by a State Fund injured worker to notify L&I of a change in address. All address changes must be submitted in writing and signed by the injured worker.

Completed and signed by a State Fund injured worker to notify L&I of a change in address. All address changes must be submitted in writing and signed by the injured worker.

To have L&I reimburse an injured worker for costs associated with purchasing their compound prescriptions less any co-payment. This form is filled out by the pharmacist. These forms will be accepted by L&I. They may not be accepted by all Medical Bill Processors due to lack of a barcode.

Used 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.

Used to bill L&I for reimbursement of home nursing services.

Used by the Crime Victims Compensation Program providers for reimbursement of home nursing services. Crime Victims Compensation Program providers are required to bill using this form.

Used for miscellaneous services of an injured worker. Such as: dental, glasses, medical equipment, transportation, home services, retraining, etc. These forms will be accepted by L&I. They may not be accepted by all Medical Bill Processors due to lack of a barcode.

To have L&I reimburse an injured worker for costs associated with purchasing their prescriptions less any co-payment. This form is filled out by the pharmacist. These forms will be accepted by L&I. They may not be accepted by all Medical Bill Processors due to lack of a barcode.

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

Used by the injured worker for reimbursment of expenses for retraining related to their worker's compensation claim. This form is signed by the injured worker and the provider.

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

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

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.

Used by L&I to assign industrial insurance classifications for workers of temporary help agencies.

Picture of a guy with Saftey Policy and Rules in his hand. Get poster printing tips.

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

To record the training costs. For use only with plans approved after 1/1/2008. For plans approved before 1/1/2008, use form F245-354-000 or F245-357-000.

To record the costs for transportation. For use only with plans approved after 1/1/2008. For plans approved before 1/1/2008, use form F245-360-000 or F245-361-000.

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

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

Used to close vocational services of an injured worker. This form is attached to Vocational Closing Report Routing Sheets F280-013-000, F280-014-000 or F252-027-000.

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

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.

You must fill out this form quarterly even if you had no workers. These forms are mailed out quarterly to all employers. For instructions on how to complete the Quarterly Report, please refer to F212-239-000 which is available on the internet.

This is an agreement between an individual and/or firm and L&I which authorizes access to L&I's computer database/application. (5 pages)

Used by only self-insured employers to comply with WAC 296-15-400. The form provides information and instructions to employees of self-insured employers in case of an injury or development of an occupational disease.

Pamphlet/booklet: Explains a worker's rights and responsibilities under industrial insurance law. Describes benefits and how to file a claim.

Pamphlet/booklet: Explains a worker's rights and responsibilities under industrial insurance law. Describes benefits and how to file a claim.

Pamphlet/booklet: Explains a worker's rights and responsibilities under industrial insurance law. Describes benefits and how to file a claim.

Pamphlet/booklet: Explains a worker's rights and responsibilities under industrial insurance law. Describes benefits and how to file a claim.

Pamphlet: Answers the most common questions about when and why an injured worker may be required to attend an independent medical exam. Includes the "IME Travel & Wage Reimbursement Request" form. This publication is for use only by self-insured businesses and their workers.

Pamphlet: Answers the most common questions about when and why an injured worker may be required to attend an independent medical exam. Includes the "IME Travel & Wage Reimbursement Request" form. This publication is for use only by self-insured businesses and their workers.

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