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

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

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

Used to order L&I medical forms.

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.

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 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 injured workers, doctors, and employers to report an industrial injury or occupational disease. This form is not on the internet. If you are an injured worker, ask your doctor for a copy of this form. Use this link to order from the warehouse. This form is not available in Spanish. There are written instructions in Spanish for completing the English form. Order F242-130-999 from the warehouse to receive the instructions in Spanish. http://www.lni.wa.gov/ClaimsIns/Providers/ROA/OrderROA.asp

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