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.

Handout: Explains to workers the basic information about L&I’s Medical Provider Network. The handout can be used with workers covered both by L&I and by self-insured employers. Applies to workers in Washington state. Includes website and phone number contact information.

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: Provides an overview of the Washington Industrial Safety and Health Act (WISHA), worker and employer rights and responsibilities, enforcement of WISHA rules, and consultation and education services L&I provides. Previously titled A Guide to WISHA

This document provides the facts necessary to make an informed decision regarding vocational retraining benefits and explains the responsibilities you and your vocational counselor (VRC) have.

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.

Checklist for homeowners on how to upgrade their pre-HUD homes to approach the HUD standards in the area of fire safety.

Checklist for homeowners on how to upgrade their pre-HUD homes to approach the HUD standards in the area of fire safety.

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. The Spanish version of the instructions are online as F800-042-999.

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. This 12-10 version is internet only.

Benefits are limited to $50,000 per claim. if your claim has met or exceeded this cap, your reopening application will be denied and we will be unable to pay any further benefits. Used by victims of crime and medical or mental health providers to request a claim be reopened.

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.

Pamphlet: Concise, easy-to-read pamphlet that explains the steps to apply for a business license and what to do if you plan to employ workers. Includes how to apply to be a registered construction contractor.

Used by pensioner to authorize L&I to deposit the pension payment to any designated financial institution. NOTE: F242-177-999 is the Direct Deposit Letter in Spanish

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.

Construction Checklist - Safety - Spanish - Lista de verificación de seguridad en la construcción

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.

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

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?

Completion of this form is not a guarantee of benefits. Payment of benefits will be decided by your claim manager.

Fact sheet: Provides an overview and resources to know your obligations when you have family members working for you. Relatives, including children, must be treated as employees with the same rights as any other paid worker in the state of Washington.

Used by Spanish speaking health-care providers to communicate an injured worker's status, physical capacities, inability to work (time-loss) and treatment plans.

Utilizado por proveedores de cuidado de la salud que hablan español para indicar la condición actual del trabajador lesionado, restricciones físicas, certificación de tiempo perdido y planes de tratamiento.

Required poster: Describes important parts of the Washington Industrial Safety and Health Act (WISHA), which provides for job safety and health of Washington employees. Note: Employers in Washington State must display this poster where workers can see it. When ordering the printed version, you will receive one 22" X 17" poster that includes both languages. Get poster printing tips.

Pamphlet/booklet: Uses a story format with dialogue and photographs to explain the hazards of cholinesterase-inhibiting pesticides, the state's monitoring program and the importance of using proper safety equipment when working with pesticides.

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.

Fact sheet: Provides information about changes to OSHA'S Federal Hazard Communication Standard, which triggers the need for changes to Washington State's standard. Rulemaking is under way in 2013. The changes are intended to improve comprehension of hazard information found in product labels to more effectively prevent injuries, illnesses and fatalities.

You can submit a Report of Accident (ROA) online https://secure.lni.wa.gov/home This form is not on the internet. If you are an injured worker, ask your doctor for a copy of this form. Order F242-130-999 from the warehouse to receive the instructions in Spanish to complete the form in English.

Si Usted piensa que ha sido discriminado o despedido por reportar los peligros existentes en su lugar de trabajo, utilice este formulario para presentar una queja.

Use this form to file a complaint when you feel you've been discriminated against or discharged for reporting a workplace safety hazard.

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.

Used by injured worker to notify claim manager and request authorization to transfer care to a different doctor. Do it online! Use the online Transfer of Care

Injured workers use this form to request reimbursement for travel expenses used to receive treatment, retraining and/or vocational services.

Bill form for use by workers to request reimbursement for authorized travel expenses.

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.

Worker Rights Complaint Form. Both the 10-2010 and 12-2011 versions are valid.

Pamphlet/booklet: Explains a worker's rights and responsibilities under industrial insurance law. Describes benefits and how to file a claim. Note: Previously titled Una gua de los trabajadores para beneficios del seguro industrial.

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.

Required poster: Reviews workers' rights under Washington's wage-and-hour laws. Topics include minimum wage, overtime, meal and rest breaks, pay periods, deductions, and employment of teens under age 18. Also reviews family leave provisions under federal and state law, and leave for spouses of deploying military personnel and victims of domestic violence. Note: Employers in both agricultural and non-agricultural industries in Washington State must display this poster where workers can see it. Get poster printing tips.

Pamphlet/booklet: Designed to help employers determine if their workers are employees or independents under Washington's workers' compensation, workplace safety, wage and hour and unemployment tax laws. Includes a short "test" and helpful references.

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.

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 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.

Employment wages and conditions agreement with Farm Labor Contractors and Workers

Agricultural Employment Standards - Chapter 296-131 WAC Spanish ESTÁNDARES DE TRABAJO AGRÍCOLA

Card: Wallet card with a toll-free telephone number where agricultural workers can call to learn about their workplace rights.

Employees use this form to report work place conditions which jeopardize workers safety and health.

Picture of a large eye with some content on when to use eye protection. Get poster printing tips.

Completion of this form is not a guarantee of benefits. Payment of benefits will be decided by your claim manager.

Used by a spouse or dependent that was chosen by the deceased worker to receive a survivor benefit. At the time the worker was determined to be totally permanently disabled he/she made a decision to leave a survivor benefit to a spouse or dependent if the worker dies.

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 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.

Fact sheet: Explains how employers could be liable for unpaid workers' compensation premiums, unpaid wages, damages and civil penalties when hiring a farm labor contractor. Outlines ways to protect against potential liability.

Fact sheet: Tells construction contractors how to protect themselves from liability for their subcontractor's unpaid workers' compensation premiums.

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.

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

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

Book: Provides employers a checklist on the requirements of the chemical hazard communication rule. Contains an extensive question-and-answer section and information on starting an employee-training program.

Use this form to say whether or not you choose to have the Cholinesterase blood tests performed.

Filled out by the provider. This form gives the recommendations by the provider of what needs to be done based on the test results on the employee.

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

Used by a spouse or dependents of a deceased worker. The workers' fatal accident or occupational disease incurred in the course of their employment. This application is needed to determine if applicant(s) is/are entitled to a survivor benefit.

Used by a spouse or dependents of a deceased worker. The workers' fatal accident or occupational disease incurred in the course of their employment. This application is needed to determine if applicant(s) is/are entitled to a survivor benefit.

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

Pamphlet/booklet: Explains the steps to register as a construction contractor in Washington State.

Crime Victim Worker Verification - Spanish FORMULARIO DE VERIFICACIÓN DE EMPLEO

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.

Large lettering: DANGER. Get poster printing tips.

Large words: Danger, Construction Area Authorized Personnel Only. Get poster printing tips.

Picture of workers on a high rise. Get poster printing tips.

Picture of workers on a high rise. Get poster printing tips.

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.

Poster: Employees have the right to report concerns about safety and health in their workplace. This poster describes "protected activities" under the Washington Industrial Safety and Health Act (WISHA) and explains what an employee should do if he/she has been punished or fired for exercising these rights. Get poster printing tips.

Completion of this form is not a guarantee of benefits. Payment of benefits will be decided by your claim manager.

Completion of this form is not a guarantee of benefits. Payment of benefits will be decided by your claim manager.

Farm Labor Contractor's Checklist to ensure compliance.

Used to file a complaint against a Farm Labor Contractor, landowner, employer, or other where a possible infraction is concerned.

Fact Sheet: Explains how to get a farm labor contractor license in order to operate legally as a farm labor contractor in Washington State.

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.

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.

Wallet card: Explains how to file a workers' compensation claim by telephone.

Identifies the effects of heat exhaustion and heat stroke on the body and what to do if you observe symptoms. Reviews prevention steps. PDF file is set up for two copies to print at one time.

Poster: Provides contact information for the Crime Victims Compensation Program. Intended for display in health-care, criminal-justice and social-service organizations that assist crime victims. The size is 11" X 17" if ordered from the Crime Victims Compensation Program. If you print from the Web, the poster will be 8.5" X 11".

Poster: Provides contact information for the Crime Victims Compensation Program. Intended for display in health-care, criminal-justice and social-service organizations that assist crime victims. This poster is 8.5" X 11."

Pamphlet/booklet: Answers questions about Washington State's Crime Victims Compensation Program, who may be eligible for benefits and how to apply.

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.

Fact sheet: Provides a checklist for consumers considering hiring a general or specialty construction contractor, reviews the permitting process, and suggests ways to avoid lien problems. Washington State law requires construction contractors to register with L&I.

Flier: Provides important information about hiring teens, including extra safety precautions, as well as legal requirements regarding minor work endorsement, hours and prohibited duties. Provides telephone, e-mail and Web contacts for more information.

Flier: Provides important information about hiring teens, including extra safety precautions, as well as legal requirements begarding minor work endorsement, hours and prohibited duties. Provides telephone, e-mail and Web contacts for more information.

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

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

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

Pamphlet/booklet: Summarizes what action to take when a workplace injury is caused by a defective product or defective machine or by a person who is not a co-worker.

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

Pamphlet/booklet: Explains structured settlement and provides an overview of eligibility and the application and approval processes. The audience for this pamphlet is injured workers who might be eligible.

Letter of Intent for School Enrollment - Spanish CARTA DE INTENCIÓN DE REGISTRO EN UNA ESCUELA

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

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.

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.

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

History of Hearing Loss and Continuation Sheet - Spanish - HISTORIA DE TRABAJO PÉRDIDA DE AUDICIÓN

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.

OJT Accountability Agreement in Spanish

State fund workers who have selected Option 2 and closed their claim can use this form to apply for access to their Option 2 training funds. To seek reimbursement, use form F245-030-000 Statement for Retraining and Job Modification Services.

Large words: Peligro Área en Construcción Solamente Personas Authorizadas. Get poster printing tips.

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

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.

8.5" X 11" sheets: Provides a summary of prevailing wage laws and rules in Spanish. This publication is only available in Spanish. For similar information in English, read the Washington State Prevailing Wage Law booklet.

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.

Full-color photographs of poison oak in different seasons help workers recognize and avoid the plant when working outdoors. Note: Poster will split over two pages if printed on 8.5" X 11" paper. Get poster printing tips.

Picture of hard hats. Get poster printing tips.

Fact sheet: Includes information regarding the benefits of Perferred Worker certification, answers to questions frequently asked by workers, phone and website contacts.

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.

Employees use this complaint form to report work place conditions which jeopardize workers safety and health.

Ask L&I to conduct an investigation into a prevailing wage violation that affects one or more employees. See box 30 on the form to see what types of complaints are covered.

Ask L&I to conduct an investigation into a prevailing wage-related issue that affects one or more employees.

Para quejas de ausencia del trabajo: Descargue y complete un formulario de Queja sobre permiso de ausencia protegida (F700-144-999)

Pamphlet/booklet: Discusses the effects of poison oak and ivy, where it is found in Washington State, how to control growth and protect workers from exposure.

This form is to be used by Spanish speaking Medical Providers outside the United States. This form now includes both English and Spanish versions of the Provider form and letters. File includes W8ECI form from IRS and instructions for the form. Both IRS form and instructions are in English. Instructions in Spansih for the W8ECI have been added. This version is not the same as the English version, which is intended for use by Providers in the United States.

Sticker: 8.5 inches X 3.5 inches

Sticker: 5 1/2 inches X 2 1/8 inches

Sticker: 5.5 inches X 2.15 inches

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

Fact sheet: Provides 10 tips for safer lifting. Contains illustrations.

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

Large words: Report All Injuries Promptly. Get poster printing tips.

Instrucciones para el Reporte de Accidente (Lesión en el trabajo, accidente o enfermedad ocupacional). This information provides instructions in Spanish for completing the F242-130-000 Report of Accident version dated 10-2012. The F242-130-000 form is in English. Use this link to order the instructions from the warehouse. http://www.lni.wa.gov/ClaimsIns/Providers/FormPub/ROA/OrderROA.asp

Large words: Report All Injuries Promptly. Get poster printing tips.

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

Tips on handling cash and how to have a safer restaurant or retail environment. Get poster printing tips.

Use this form to record the minutes from your safety meetings - these records must be retained for one year from the date of each meeting

Pamphlet/booklet: Describes the benefits of free employer consultations offered by L&I's Division of Occupational Safety and Health (DOSH). These services include on-site safety and/or industrial hygiene consultations, ergonomics assistance and risk management advice.

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 been paid, and a permanent partial disability award is also being paid.

Picture of a large eye with some content on when to use eye protection. Get poster printing tips.

Pamphlet/booklet: Answers questions employers, parents and teens may have about employing teen workers (ages 14-17). Explains non-agriculture work rules, including the necessary permits, hours and work conditions. Provides links to other resources.

Pamphlet/booklet: Summarizes the legal rights and options an injured worker has if a third-party action pertains to his/her workers' compensation claim. Includes the form that must be completed by the worker. Note: The form can be filled in using Adobe Reader, but must be printed, signed and mailed.

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

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

Vocational Questionnaire/Work History for use by Vocational Providers serving injured workers

Fact sheet: Provides a brief overview of the worker rights administered by the Department of Labor and Industries. These include certain employment-related rights and rights pertaining to workplace safety and workers' compensation benefits.

Fact sheet: Explains workers' rights when they are employed by a farm labor contractor. Topics covered include workplace safety, rest and meal breaks, and help if injured on the job.

Fact sheet: Provides an overview of rights workers have when they are employed by a farm labor contractor. Several topics are covered, including regular wages, workplace safety, and help if injured on the job.

Fact sheet: Summarizes workers' rights and responsibilities regarding minimum wage, pay, work hours and overtime and explains how to file a wage complaint. Includes answers to several commonly asked questions.

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: Explains workers' legal right to file a workplace injury claim and how to file a complaint if discrimination has occurred.

Pamphlet/booklet: Explains Washington's chemical hazard communication standard, which requires employers to inform their employees about hazardous chemicals in the workplace and to train them in their proper use.

Pamphlet/booklet: Answers many questions employers and minor workers have about employing minors. Covers agriculture work rules, including the necessary permits, hours and work conditions for workers 12-17 years of age.

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.

Pamphlet/booklet: A pocket-sized bilingual booklet to encourage agricultural workers to keep track of their daily work hours and earnings.

Pamphlet/booklet: Answers the most common questions about independent medical exams and when and why an injured worker may be required to receive one. Includes the "IME Travel & Wage Reimbursement Request" form.

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/booklet: Briefly reviews the symptoms and causes of work-related asthma and explains prevention and treatment approaches.

Pamphlet/booklet: Covers things you should consider when altering your home. Defines what is meant by alteration, repair and replacement and includes tips for hiring a registered contractor. It also includes contact information for L&I Consumer Assistance Program for owners of new manufactured/mobile homes.

Pamphlet/booklet: Covers things you should consider when altering your home. Defines what is meant by alteration, repair and replacement and includes tips for hiring a registered contractor. It also includes contact information for L&I Consumer Assistance Program for owners of new manufactured/mobile homes.

Fact sheet: Serves as L&I's official privacy notice. States how L&I may use and share the pesonal information it collects. It also informs the public how they can file a complaint if they believe L&I has misused or inappropriately disclosed their personal information.

Booklet/pamphlet: Explains the limits on work teens under age 18 can perform in the construction industry, discusses the importance of training and emphasizes safety. Includes a checklist of "do's" and "don'ts" for employers, plus other resources.