Forms and Publications

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Application to Reopen Claim Due to Worsening Condition
Form
F242-079-000

World Language(s):
English/Español
Español  
Job Modification Assistance Application
Form
F245-346-000

World Language(s):
Español  
L&I Benefits for Workers Who Are Terminally Ill
Publication
F252-094-000  
Occupational Disease & Employment History
Form
F242-071-000

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

World Language(s):
Español  
Provider's Initial Report (PIR)
Form
F207-028-000  
Report of Accident (ROA) Workplace Injury, Accident or Occupational Disease
Form
F242-130-000

World Language(s):
Español  
Self-Insurance Report of Occupational Injury or Disease (SIF-5)
Form
F207-005-000  
Self-Insurer Accident Report (SIF-2)
Form
F207-002-000  
Vocational Training Plan Ownership Agreement for Tools and Equipment
Form
F245-351-000

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

World Language(s):
Español  
Application to Reopen Claim due to Worsening Condition / Solictud para volver a abrir un reclamo (English/español)
Form
F242-079-909

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

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

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

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

World Language(s):
Inglés
Español  
Solicitud para reabrir un reclamo debido al empeoramiento de la condición
Form
F242-079-999

World Language(s):
Inglés
English/Español  





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