Also available in: Spanish

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.

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.

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 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).

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.

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

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

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.

To record the training costs. For use only with plans approved after 1/1/2008.

This form is used by self-insured injured workers who want to transfer their medical care.  Self-insured workers should complete the form and send it to their employer or their Third Party Representative

Este formulario es utilizado por los trabajadores autoasegurados que desean transferir su cuidado mdico. Los trabajadores autoasegurados deben completar este formulario y enviarlo a su empleador o a su Representante de Terceros.

To record the costs for transportation. For use only with plans approved after 1/1/2008.

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.

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 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 employers to assist in fulfilling surety requirements.

Used by employers to apply for self-insurance certification.

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

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.

To record the costs for housing and board. For use only with plans approved after 1/1/2008.

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

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 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.

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.

To record the work plan time. For use only with plans approved after 1/1/2008.

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

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.

Instructions for filling out the quarterly statement of supplemental benefits.

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

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

Schedule of Future Payments for the Balance of the Permanent Partial Disability Award.

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 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, 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.

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

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.

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. See the Pharmacy Billing Instructions (F248-021-000) for information on completing this form.

Bill form for providers that bill the department for claim-related retraining and job modification services. See the Retraining and Job Modification Billing Instructions (F248-015-000) for information on completing this form.

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.

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.