Formularios y publicaciones en español por nÃºmero


Formularios y publicaciones en español por nÃºmero	en inglés

Número	Título
BLS 700-028	Minor Work Permit (Master Business Application) Link is to the Dept. of Licensing online form: Required for employers who hire minors and is obtained by completing the Master Business Application. Also available from L&I warehouse.
F100-002-000	Apprentice Work Progress Record Worksheets used to record the number of hours worked and Related Supplemental Instruction hours during a registered apprenticeship on a monthly basis. If used, a copy is usually given to the program monthly.
F100-012-000	Program Equal Employment Opportunity Activity Documentation Used to record individual equal employment opportunity activities conducted by Apprenticeship Programs.
F100-016-000	Apprenticeship Agreement Used by the registered apprenticeship progam to setup an agreement with the apprentice.
F100-019-000	On-the-Job Training Agreement Card This card is used by an OJT Apprenticeship program ONLY. To recieve this form, you must contact the Apprenticeship Section.
F100-021-000	Request for Change of Status - Apprenticeship/Training Agreements and Training Agents Used to request a change of status for apprentices, the training agreements or the training agents. These are normally accompanied by Committee meeting minutes when submitted.
F100-022-000	The Apprenticeship Advantage: Earn While You Learn! Fact sheet: Introduces apprenticeship to younger people. Explains the benefits of apprenticeship, a program of study where apprentices earn wages while learning a skilled profession. Includes contact information for L&I's apprenticeship coordinators around the state.
F100-024-000	Suggested Procedure for Apprenticeship Committee Meetings Suggestions on how to have successful apprenticeship committee meetings.
F100-029-000	Minutes of Apprenticeship Committee Meeting Example of how the minutes for an Apprenticeship Committee meeting should be recorded. Submit this to L&I Apprenticeship section within 30 days of the meeting.
F100-030-000	Request for Revision of Standards Used to request a revision of standards except for committee members.
F100-031-000	Request for Revision of Committee Used to request revision of committees to include changing the title of the standards, sub-committees, and training directors/coordinators.
F100-033-000	Application for Apprenticeship EXAMPLE ONLY: Example of an application to apply for an apprenticeship. Registered Apprenticeship Programs use their own forms. NOT TO BE USED TO REQUEST PLUMBER or ELECTRICAL TRAINEE CARD.
F100-041-000	Washington State Apprenticeship Programs Catalog Book: Provides an overview of apprenticeship, explains general requirements, lists the apprenticeship programs in Washington Stateand, and provides contact information. The version available online may contain more up-to-date information than the May 2009 printed edition.
F100-045-000	Apprenticeship Applicant Register Example: Used for tracking applicants for an apprenticeship program. Registered Apprenticeship Programs use their own forms.
F100-049-000	Request for New Standards Request for new apprenticeship standards.
F100-050-000	Journey Level Wage Rate from which apprentices' wages rates are computed. Used to submitted the Journey-level wage rate from which the apprentices' wage rate is computed. Form must be submitteed at least annually or sooner if the rates change.
F100-228-000	Related Supplemental Instruction Hours Used by Apprenticeship programs to submit related instruction hours to L&I Apprenticeship section. It is preferred that programs use the combined RSI/OJT reporting form. RSI Hours must be reported quarterly.
F100-229-000	On-The-Job Training Work Hours Used to report the work hours for an on-the-job training employee.
F100-303-000	Request for Cancellation of Program Used for cancelling an apprenticeship program.
F100-500-000	Authorization of Signature This gives individuals other than the Secretary or Chairman authorization to sign ALL Papers or just Registration Cards. Must be signed by a quorum of the Apprenticeship Committee.
F100-503-000	Apprenticeship Transfer Agreement Used to allow an apprentice to transfer from a Washington State Registered apprenticeship program to another Washington State Registered program.
F100-504-000	Request for New Apprenticeship Committee Used to establish a new apprenticeship committee and list it's employer/employee representatives.
F100-505-000	Apprenticeship Complaint (Not for Apprenticeship Appeals) Used to file a complaint on a apprenticeship program, committee, training agent, etc. NOT be used by Apprentices appealing Committee Decisions.
F100-508-000	Approved Training Agent Used to allow an employer to train apprentices as part of a Registered Apprenticeship program.
F100-509-000	Instructor's Report of Accident / Incident This form must be submitted to L&I's Apprenticeship Section by the Instructor at the time of the incident and the appropriate Apprenticeship Program within 5 days of an accident/incident of an apprentice/trainee during Related Supplemental Intruction (RSI).
F100-510-000	Request for Cancellation of New Apprenticeship Committee To request a cancellation of a new apprenticeship committee which never has a "Request for New Standards" approved by the WSATC
F100-511-000	Notice to Attending Physician of Apprentice / On-the-Job-Training Accident / Incident A notice to the attending physician that the individual is a Registered Apprentice and to attach this form to the Accident Report of Industry Injury or Occupational Disease (F242-130-000).
F100-512-000	Registered Apprenticeship Program Address/Mailing Information Update Used by the Registered Apprenticeship Program to update their address or mailing information. (Note: This does update your program standards information.)
F100-513-000	Equal Employment Opportunity (EEO) Resource & Referral Update Form Used by an organization to get on the Apprenticeship Program equal opportunity resources list or use to update their information on the list.
F100-515-000	Log of Good Faith Effort Documentation This is for Registered Apprenticeship Programs to record Good Faith Effort activities in accordance with their Registered Apprenticeship Standards (Equal Employment Opportunity Plan)
F100-516-000	Notice of Contest or Objection to Proposed Standards of Apprenticeship Used by competitor to contest or object to a proposed standards of apprenticeship, new occupation or revised geographical area. Submit this form at least 20 days prior to a Council meeting.
F100-517-000	NOTICE - Your Right to Register Equal Employment Opportunity (EEO) Complaints This notice is to be posted by Apprenticeship Programs in plain view to inform apprentices or apprenticeship applicants of who to contact in regards to EEO Complaints.
F100-518-000	Related Supplemental Instruction / On-the-Job Training Hours Used to track apprentices/trainees on-the-job training hours.
F100-519-000	Apprenticeship Related Supplemental Instruction Plan Review Glossary of Terms Glossary of terms used with Apprenticeship Related Supplemental Instruction (RSI) Plan Review form amd RSI Plan.
F100-520-000	Apprenticeship Related Supplemental Instruction (RSI) Plan Review Used by apprenticeship programs/sponsors as part of the process of getting new programs/standards/occupations approved.
F100-521-000	Process for Developing and Approving Related Supplemental Instruction (RSI) Describes the process for getting approval of new or revised RSI for new apprenticeship programs/standards/occupations.
F100-522-000	Standards of Apprenticeship Blank form for creating Registered Apprenticeship Standards. This document is used to create Apprenticeship Standards which will go before the Washington State Apprenticeship and Training Council for approval.
F100-523-000	Training Agent Agreement and Understanding of Equal Employment Opportunity (EEO) Requirements of the Apprenticeship Commmittee - Alternate Selection Process This should be signed by all employers who are Training Agents with Apprenticeship Programs that use an Alternate Selection Process. This also explains their obligations and rights as part of this process.
F100-526-000	Apprenticeship Advantage poster Poster: Introduces apprenticeship, especially for younger people. Promotes the benefits of apprenticeship and includes contact information to learn more.
F101-002-000	Employers' Guide to Industrial Insurance 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.
F101-009-000	Request for Public Records To request public records from Washington State Dept. of Labor and Industries.
F101-010-000	Authorization to Release 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.
F101-010-111	Request for Claim Information Used by workers, workers' representatives, employers or employers' representatives to request claim information from L&I.
F101-010-999	AutorizaciÃ³n Para Proveer InformaciÃ³n De Reclamos 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.
F101-054-000	Workplace Posters: Required and Recommended Fact sheet: Lists the posters L&I and other state and federal agencies require employers to post in their places of business. Several recommended posters are listed as well. The URLs for posters available online and and telephone numbers to request printed posters are also provided. See also L&I Workplace Posters: Required and Recommended.
F101-055-909	Your Privacy Is Important to Us (English/Spanish) 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.
F101-060-000	Web Advertising Card Flier: Promotes L&I's web site and lists the URLs for online services.
F101-061-404	What Are Your Rights as a Worker? (English/Russian) 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.
F101-061-505	What Are Your Rights as a Worker? (English/Vietnamese) 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.
F101-061-606	What Are Your Rights as a Worker? (English/Cambodian) 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.
F101-061-707	What Are Your Rights as a Worker? (English/Korean) 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.
F101-061-909	What Are Your Rights as a Worker? (English/Spanish) 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.
F101-063-000	A Guide to Hiring Independent Contractors in Washington State 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.
F101-063-999	GuÃa para contratar Contratistas Independientes en el Estado de Washington 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.
F101-068-000	2005 Annual Report - Department of Labor & Industries Provides a statistical overview of results achieved in fiscal year 2005 (July 1, 2004, through June 30, 2005), budget information and a narrative introduction to the Department of Labor and Industries.
F101-077-303	If Family Members Work for You, Know Your Obligations (English/Thai) 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.
F101-077-404	If Family Members Work for You, Know Your Obligations (English/Russian) 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.
F101-077-505	If Family Members Work for You, Know Your Obligations (English/Vietnamese) 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.
F101-077-707	If Family Members Work for You, Know Your Obligations (English/Korean) 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.
F101-077-808	If Family Members Work for You, Know Your Obligations (English/Chinese) 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
F101-077-909	If Family Members Work for You, Know Your Obligations (English/Spanish) - Conozca sus obligaciones cuando miembros de su familia trabajan para usted 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.
F101-078-000	2006 Annual Report - Department of Labor & Industries Provides a statistical overview of results achieved in fiscal year 2006 (July 1, 2005, through June 30, 2006), budget information and a narrative introduction to the Department of Labor & Industries.
F101-079-000	Applying for Your Washington Business License: A Step-by-Step Guide 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.
F101-079-999	Applying for Your Washington Business License: A Step-by-Step Guide-Spanish (Aplicando para su Licencia de Negocio en Washington: Una guÃa detallada 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.
F101-080-000	2007 Annual Report - Department of Labor & Industries Provides a statistical overview of results achieved in fiscal year 2007 (July 1, 2006, through June 30, 2007), budget information and a narrative introduction to the Department of Labor & Industries.
F101-084-000	Directory of Web Resources for Washington Businesses 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.
F101-086-000	2008 Annual Report for the Washington State Fund: Washington's State-run Workers' Compensation Program 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.
F101-087-000	Doing Business with the State of Washington: A Guide to Washington State Bid Opportunities Pamphlet/booklet: Provides an overview of bid opportunities and processes for Washington State government with specific contact information for the Department of Labor & Industries.
F101-088-000	Small Business Liaison Info Card Introduces L&I's Small Business Liaison and the services provided, along with information on subscribing to the e-newsletter, L&I News for Small Business.
F101-091-000	Plan for and Pay Your Taxes Information card: Introduces Washington State's 28-minute DVD that covers state business taxes and workers' compensation premiums and provides information on how to file.
F101-091-034	Plan for and Pay Your Taxes DVD DVD: Covers state business taxes and workers' compensation premiums and provides information on how to file. This 28-minute DVD can help employers plan ahead and obtain more information.
F120-097-000	L&I Facility Use Application and Agreement for Government Agencies Use this form if you are a government agency wanting to use the L&I facility located at 7273 Linderson Way SW; Tumwater, WA. (4 pages)
F120-116-000	Application to Establish an Factory Assembled Structure Deposit Account with the Dept. of Labor and Industries Use to establish a factory assembled structure (FAS) deposit account. FAS deposit accounts are for businesses or other entities that are not currently licensed or registered with L&I as electrical or construction contractors but are legally required to purchase work permits from L&I. (3 pgs)
F130-004-909	Protegiendo a los trabajadores de Washington (Protecting Washington Workers) DVD: An innovative tool to teach Spanish-speaking workers about workplace rights while introducing English terminology.
F200-001-000	Getting Back to Work: It's Your Job and Your Future 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.
F200-001-999	Getting Back to Work: It's Your Job and Your Future-Spanish (Regresando a trabajar es su trabajo y su futuro) 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.
F200-002-000	Attending Doctor's Return-to-Work Desk Reference Book: Discusses best practices in occupational medicine that help return an injured worker to his/her job as soon as medically possible. Identifies resources available from L&I and explains how to bill for return-to-work services. Three hours of Category 1 CME credit are offered for completing the test inside the handbook.
F200-003-000	Employer's Return-to-Work Guide Pamphlet/booklet: Explains the benefits of 'return to work' from the employer's perspective, describes RTW options, and provides resource and contact information.
F200-005-000	2004 Year in Review Pamphlet/booklet: Provides a financial summary of Washington State's workers' compensation system, July 1, 2003 through June 30, 2004.
F200-006-000	Help Fight Workers' Comp Fraud Flier: Describes the New Hire Registry operated by the Department of Social and Health Services and how employers using it can help fight workers' compensation fraud.
F200-009-000	2005 Year in Review 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.
F200-010-000	Reporting Injuries at Work, Employee Wallet Cards 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.
F200-010-999	Reporting Injuries at Work, Employee Wallet Cards (Spanish) 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.
F200-011-000	Claim & Account Center flier Provides a brief overview of L&I's Claim & Account Center. This online application allows authorized users to check the status of a workplace injury claim and gives employers access to their account, including rates and classifications.
F200-012-000	2006 Year in Review Pamphlet: Provides a financial summary of Washington State's workers' compensation system, July 1, 2005, through June 30, 2006.
F200-013-000	2007 Year in Review 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.
F200-015-000	2008 Year in Review 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.
F207-001-000	Application for Self-Insurance Certification Used by employers to apply for self-insurance certification.
F207-005-000	Self-Insurance Report of Occupational Injury or Disease (SIF-5) Used by only self-insured employers or their representatives to report initial time loss payments or to request interlocutory, wage, overpayment or closure orders.
F207-006-000	Quarterly Report for Self-Insured Business 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.
F207-007-000	Annual Report of Self-Insured Business, 2008 (SIF-7) 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.
F207-011-000	Quarterly Statement of Supplemental Benefits Paid for Self-Insured Employers Used by self-insured employers to report their quarterly statement of supplemental benefits.
F207-011-111	Quarterly Statement of Supplemental Benefits Instructions Instructions for filling out the quarterly statement of supplemental benefits.
F207-011-222	Social Security Offset Calculations Only Quarterly Statement of Supplemental Benefits Paid for Self-Insured Employers Used by self-insured employers to request reimbursement from L&I for cost-of-living-adjustments paid to injured workers.
F207-020-111	Self-Insured Employers' Medical Only Claim Closure Order and Notice 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.
F207-020-666	Self-Insured Employers' Medical Only Claim Closure Order and Notice - Cambodian 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.
F207-020-777	Self-Insured Employers' Medical Only Claim Closure Order and Notice - Korean 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.
F207-020-999	NotificaciÃ³n de DecisiÃ³n de Cierre para reclamos Ãšnicamente MÃ©dicos para Empleadores Autoasegurados 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.
F207-037-909	Notice to Employees -- Self-Insurance (English/Spanish) 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.
F207-039-000	Special Escrow Agreement 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.
F207-040-000	Agreement of Assumption and Guarantee of Workers' Compensation Liabilities - Application of Certification Used by an employer to apply for self-insurance.
F207-040-001	Agreement of Assumption and Guarantee of Workers' Compensation Liabilities (Certified 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.
F207-058-000	Assignment of Account Agreement Used by a self-insured employer as an option to provide collateral for a total permanent disability claim.
F207-065-000	Self-Insurer's Pension Bond Used by self-insured employers as an option to provide collateral for a permanent total disability claim.
F207-068-000	Self-Insurer's Bond - Existing Liabilities Used to provide collateral for a self-insured program.
F207-070-000	Self-Insured Employers' Time Loss Claim Closure Order and Notice 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.
F207-070-666	Self-Insured Employers' Time Loss Claim Closure Order and Notice -Cambodian 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.
F207-070-777	Self-Insured Employers' Time Loss Claim Closure Order and Notice - Korean 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.
F207-070-999	NotificaciÃ³n de DecisiÃ³n de Cierre para reclamos de Tiempo Perdido para Empleadores Autoasegurados 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.
F207-079-000	Employers' Guide to Self-Insurance in Washington State Book: Explains the process for employers to provide their own industrial insurance (workersâ€™ compensation) coverage in Washington State. Also reviews surety requirements for self-insurance, reporting and recordkeeping requirements, claims processing, and compliance and legal issues.
F207-085-000	A Guide to Industrial Insurance Benefits for Employees of Self-insured Businesses 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.
F207-085-999	A Guide to Industrial Insurance Benefits for Employees of Self-insured Businesses - Spanish (GuÃa de beneficios de seguro industrial para los empleados de empresas autoaseguradas) 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.
F207-095-000	Self-Insured Employer Certificate of Excess Insurance Used to provide excess insurance for a self-insurance program.
F207-110-000	Preparing for Your Self-Insurance Audit Pamphlet/booklet: Helps self-insured employers understand and prepare for an audit.
F207-112-000	Irrevocable Stand By Letter of Credit Used by a self-insurer to provide collateral for its program only if it has a net worth in excess of $500 million.
F207-112-111	Amendment of Irrevocable Standby Letter of Credit Used by a self-insured employer to change items on the surety document such as amount of letter of credit issued as collateral.
F207-113-000	Memorandum of Understanding Irrevocable Standby Letter of Credit 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.
F207-120-000	Pension Bond Rider 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.
F207-125-000	Annual Supplemental Surety Information Used by self-insured employers to assist in fulfilling surety requirements.
F207-129-000	Memorandum of Understanding 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.
F207-134-000	Surety Rider 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.
F207-137-000	Special Escrow Account - Amendment Agreement 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.
F207-143-000	Acknowledgement of Security Interest 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.
F207-155-000	Workers' Compensation Filing Information 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.
F207-155-999	CÃ³mo registrar un reclamo para la compensaciÃ³n del trabajador con empresas autoaseguradas 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.
F207-156-000	SIF-5A Cover Sheet: Wage Calculations Used by only self-insured employers and their representatives to calculate and report injured workersâ€™ wages and time loss compensation rates.
F207-163-000	SIF-4 Self Insured Employer's Request for Denial of 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.
F207-164-000	Self-Insured Employers' Permanent Partial Disability Closure Order and Notice - PPD-TL 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.
F207-164-666	Self-Insured Employers' Permanent Partial Disability Closure Order and Notice - PPD-TL - Cambodian 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.
F207-164-777	Self-Insured Employers' Permanent Partial Disability Closure Order and Notice - PPD-TL -Korean 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.
F207-164-999	NotificaciÃ³n de DecisiÃ³n de Cierre con Discapacidad Parcial Permanente para Empleadores Autoasegurados - PPD-TL 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.
F207-165-000	Self-Insured Employers' Permanent Partial Disability Closure Order and Notice - PPD-NTL 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.
F207-165-666	Self-Insured Employers' Permanent Partial Disability Closure Order and Notice - PPD-NTL -Cambodian 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.
F207-165-777	Self-Insured Employers' Permanent Partial Disability Closure Order and Notice - PPD-NTL - Korean 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.
F207-165-999	NotificaciÃ³n de DecisiÃ³n de Cierre con Discapacidad Parcial Permanente para Empleadores Autoasegurados - PPD-NTL 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.
F207-171-000	Self-Insurance Vocational Services Closing Cover Sheet Used by self-insured employers, their representatives, and vocational counselors to summarize the outcome of a vocational rehabilitation plan when submitting the closing report.
F207-176-000	Self-Insurance Certification Questionnaire Used by employers applying to become self-insured to describe their proposed workers' compensation program.
F207-177-000	Application for Self-Insurance Claims Administrator Test This form is used by experienced claims adjudicators for applying to take the Self-Insurance Claims Administrator Test.
F207-190-000	Self-Insurance Vocational Reporting Form 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).
F207-191-000	Self Insurance Continuing Education Report of Course Completion Used by department-approved claims administrators to report course completion for obtaining continuing education credit.
F207-192-000	Self Insurance Continuing Education Sponsor/Instructor Application for Course Approval 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.
F207-193-000	Self-Insurance Electronic Data Reporting System (SIEDRS) Enrollment Form 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
F207-194-000	Self-Insurance Electronic Data Reporting System (SIEDRS): Enrollment Package 2.0 Book: Explains the technical requirements for participating in SIEDRS, the Self-Insurance Electronic Data Reporting System
F207-195-000	Self Insurance Training Course Registration Used by interested parties to register to attend continuing education courses provided by the L&I Self Insurance Section.
F207-197-000	SIEDRS (Self-Insurance Electronic Data Reporting System) Data Change Request This is a data change request form. F207-193-000 is the Self-Insurance Electronic Data Reporting System (SIEDRS) Enrollment Form
F207-201-000	Help for Injured Workers of Self-Insured Businesses 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.
F207-202-000	Your Independent Medical Exam: For Employees of Self-Insured Businesses 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.
F207-202-999	Your Independent Medical Exam: For Employees of Self-Insured Businesses-Spanish (Su Examen MÃ©dico Independiente: Para empleadores de negocios autoasegurados) 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.
F208-063-000	Medical Forms Request Used to order L&I medical forms.
F211-141-000	Certificate of Coverage - SAMPLE ONLY Sample of what the Certificate of Coverage looks like. You must order the forms you cannot download it off the internet.
F211-141-999	Certificado de Cobertura - Ejemplo Sample of what the Certificate of Coverage looks like. You must order the forms you cannot download it off the internet.
F212-034-000	Maritime Coverage Used by the employer as a quick reference guide to explain which maritime jobs may or may not be covered by L&I.
F212-044-000	Coverage Agreement An agreement between a worker and employer which states the worker's employment is principally localized in Washington state or another state.
F212-049-000	Guide for Payroll Service Providers Bulk Filing Worker's Compensation Quarterly Reports Guide for Payroll Service Providers Bulk Filing Worker's Compensation Quarterly Reports
F212-050-000	Drywall Industry - Owner/Sub-Contractor Report Used by drywall companies to file their quarterly report. Must accompany the Supplemental Quarterly Report for the Drywall Industry (F212-051-000).
F212-051-000	Supplemental Quarterly Report for the Drywall Industry Used by drywall companies to file their quarterly report. Must accompany the Drywall Industry Owner/Sub-Contractor Report (F212-050-000).
F212-055-000	Worker's Compensaiton Employer's Quarterly Report for Industrial Insurance - SAMPLE ONLY 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.
F212-196-000	Sports Teams Coverage Agreement 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.
F212-197-000	Workers' Compensation File Information Contract 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)
F212-222-000	Workers' Compensation Record Keeping and Reporting Guides Packet: Contains eight quick reference cards covering topics related to workers' compensation record keeping and reporting. Topics include: computering worker hours, standard exception classifications, excluded employments and corporate officers.
F212-223-000	Mechanized Logging Supplemental Quarterly Report Used by an employer to be submitted with the Employer's Quarterly Report for Industrial Insurance as a supplemental reporting form.
F212-224-000	Quarterly Reporting for Drywall 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.
F212-224-999	Reporte Trimestral Para La Industria De Tabla De Yeso 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.
F212-233-000	Washington Workers Insured Out-of-State: Employerâ€™s Supplemental Quarterly Report for Workersâ€™ Compensation The purpose of 212-233-000 Supplemental reporting form is to allow employers to report out-of-state wages and hours as per the requirement in WAC 296-17-25203(8).
F212-234-000	Application for out of State Supplemental Reporting The purpose of form 212-234-000 -Out of state applications- is to provide a means for an employer to formally request to receive the out-of-state supplemental report for a specific year and state. The form will also allow the department to convey out-of-state reporting requirements and to obtain information needed by the department to set a business up for supplemental reporting.
F212-235-000	Authorization for L&I to Accept and Process Quarterly Report from Accountant Used by employers to give authorization to their accountants to submit quarterly reports in their behalf.
F212-239-000	Instructions for completing the Worker's Compensation Employer's Quarterly Report 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.
F213-004-000	Cancellation of Elective Coverage - Sole Proprietors/Partner, Member of Limited Liability Company (LLC), Member of Limited Liability Partnership (LLP) or For-Profit Corporate Officers 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.
F213-005-000	Cancellation of Elective Coverage for Excluded Employments 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.
F213-008-000	Construction Industry Classification Guide - Part 1 to Part 3 Book (loose-leaf manual): Helps contractors properly classify for industrial insurance purposes the work being performed by their employees on new wood-frame building construction projects. Part 1 - Preface, Introduction, Overview, Record-keeping Requirements, Phases of Construction (Site Preparation, Foundation and Flatwork) Part 2 - Phases of Construction (continued) -- Framing the Structure, Utility Construction, Enclosing the Structure, Interior Finish Work, Finishing the Site, Miscellaneous Operations Part 3 - Appendixes
F213-010-000	Contract: Report By Landowner - Forest, Range & Timber Industry 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.
F213-011-000	Contract: Report By Contractor - Forest, Range & Timber Industry 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.
F213-013-000	Reforestation Contract Supplemental Report - Forest, Range and Timber Industry 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).
F213-015-000	Reforestation Industry Continuation Sheet (Over $10,000) 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.
F213-019-000	Temporary Services Guide to Workers' Compensation Insurance Used by L&I to assign industrial insurance classifications for workers of temporary help agencies.
F213-022-000	The ABCs of Classifications in Washington Book: Aids in understanding Washington State's workers' compensation classification system and how classifications are applied to different types of businesses.
F213-023-000	Student Volunteers and Workers' Compensation Coverage Fact sheet: Covers availability, limitations and cost of Washington State's optional workers' compensation coverage for student volunteers.
F213-042-000	Application for Elective Coverage - Sole Proprietor, Partners, For-Profit Corporate Officers, or Member/Managers of Limited Liability Company (LLC) 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.
F213-112-000	Application for Elective Coverage of Excluded Employments 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.
F213-113-000	Application for Exclusion/Inclusion - Mandatory Coverage (Family Farm) To exclude or include coverage for a family farm's children.
F214-010-000	Corporate Officers Quick reference card: Explains the criteria to allow a corporate officer to be exempt from industrial insurance (workers' compensation) coverage.
F214-011-000	Record Keeping Quick reference card: Identifies the type of records employers, including construction contractors, need to keep to allow L&I to compute premiums.
F214-012-000	Independent Contractors 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.
F214-013-000	Excluded and Exempt Employments Quick reference card: Provides a list of employments excluded from workers' compensation coverage, including those eligible for optional coverage.
F214-014-000	Computing Worker Hours 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
F214-016-000	Standard Exception Classification 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.
F214-020-000	Audit Reference Card 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.
F214-021-000	Limited Liability Companies (LLC) Quick reference card: Reviews the requirements for members or managers of limited liability companies to be exempt from workers' compensation (industrial insurance) coverage.
F214-024-000	Drywall Contractors Quick reference guide: Used by drywall contractors to get answers to questions about being a drywall contractor and how it relates to L&I.
F215-038-000	Request for Contract Release This is the form used by public agencies to request L&Iâ€™s approval to release retainage. All known contractors are to be listed on the request form. This form is used for L&I purposes only. Public agencies submit a different form to DOR to obtain approval from DOR and ESD. There are two files - am image only Adobe file and a fillable word document.
F225-004-000	Your Workers' Compensation Rate Notice - SAMPLE ONLY Form used to compute Your Workers' Compensation premiums. Page 2 has rate notice definitions. Sample only.
F241-021-000	Request for Manuals from Claims Training 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.
F242-052-000	Worker Verification Form 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.
F242-052-999	Formulario de VerificaciÃ³n de Empleo 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.
F242-055-000	Verification of School Enrollment Used by the student and a school official each quarter to verify school enrollment.
F242-055-999	Verificiation of School Enrollment - Spanish VERIFICACIÃ“N DE REGISTRO EN LA ESCUELA Verificiation of School Enrollment - Spanish VERIFICACIÃ“N DE REGISTRO EN LA ESCUELA
F242-056-000	Claim for Pension by Spouse or Children Used by surviving spouse or children of a deceased worker to file a claim for benefits.
F242-056-999	Claim for Pension by Spouse or Children - Spanish Reclamo para PensiÃ³n de Esposo(a) o Los NiÃ±os Used by surviving spouse or children of a deceased worker to file a claim for benefits.
F242-062-000	Claim for Pension By Dependents Used by dependents of a deceased worker to file a claim for benefits.
F242-062-999	Reclamo for PensiÃ³n por Dependientes Used by dependents of a deceased worker to file a claim for benefits.
F242-067-000	Inquiry for Assessment of Damages Your answers to these questions will be used to assist in evaluating your damages if a claim is made against a liable third party.
F242-071-000	Occupational Disease & Employment History Injured worker fills this out to document possible occupational disease and to show work history.
F242-071-111	Occupational Disease & Employment History (Cont) Injuried worker fills out this document to show more work history. This form goes with Occupational Disease & Employment History (F242-071-000).
F242-071-911	ContinuaciÃ³n del Historial de Trabajo Enfermedad Ocupacional Injured worker fills this out to document possible occupational disease and to show work history.
F242-071-999	Historial de Trabajo (Enfermedad Ocupacional) Injuried worker fills out this document to show more work history. This form goes with Occupational Disease & Employment History (F242-071-000).
F242-079-000	Application to Reopen Claim Due to Worsening Condition 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.
F242-079-999	Application to Reopen Claim due to Worsening Condition - Spanish APLICACIÃ“N PARA REABRIR UN RECLAMO 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.
F242-104-000	Workers' Guide to Industrial Insurance Benefits Pamphlet/booklet: Explains a worker's rights and responsibilities under industrial insurance law. Describes benefits and how to file a claim.
F242-104-111	Workers' Guide to Industrial Insurance - Russian Pamphlet/booklet: Explains a worker's rights and responsibilities under industrial insurance law. Describes benefits and how to file a claim.
F242-104-222	Workers' Guide to Industrial Insurance - Vietnamese Pamphlet/booklet: Explains a worker's rights and responsibilities under industrial insurance law. Describes benefits and how to file a claim.
F242-104-999	Workers' Guide to Industrial Insurance Benefits - Spanish (GuÃa de los trabajadores para beneficios del seguro industrial) Pamphlet/booklet: Explains a worker's rights and responsibilities under industrial insurance law. Describes benefits and how to file a claim.
F242-107-000	Address Change Request 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.
F242-107-999	Solicitud de Cambio de Domicilio 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.
F242-109-000	Employment History Form Used by Injured Worker to report their employment history for the past three years, and the detailed wages for each job.
F242-109-999	Historial de Empleo Used by injured worker to report their employment history for the past three years and the wages at each job.
F242-130-000	Report of Industrial Injury or Occupational Disease (Accident Report ) (ROA) 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.
F242-130-999	Informe de Lesion o Enfermedad Ocupacional - Hoja de Referencia Used by Spanish-speaking injured worker who is filing a workers' compensation claim for an industrial injury or occupational disease. This form provides instructions in Spanish for completing the F242-130-000 Report of Industrial Injury or Occupational Disease. Available in L&I warehouse August 1.
F242-173-111	Declaration of Entitlement for Widow or Widower Benefits Under Industrial Insurance 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.
F242-173-222	Declaration of Entitlement for Guardian Benefits under Industrial Insurance 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.
F242-173-333	Declaration of Entitlement for Dependent of Deceased Worker Benefits Under Industrial Insurance 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.
F242-173-444	Declaration of Entitlement for Totally Disabled Worker Benefits Under Industrial Insurance 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.
F242-173-911	DeclaraciÃ³n De Derechos Para Viuda(O) Bajo El Programa De CompensaciÃ³n Y Beneficios Para Trabajadores 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.
F242-173-922	DeclaraciÃ³n De Derechos Para Padres O Tutor Bajo El Programa De CompensaciÃ³n Y Beneficios Para Trabajadores 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.
F242-173-933	DeclaraciÃ³n De Derechos Para Dependiente Del Trabajador Fallecido Bajo El Programa De CompensaciÃ³n Y Beneficios Para Trabajadores 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.
F242-173-944	DeclaraciÃ³n De Derechos Para Trabajador Totalmente Discapacitado Bajo El Programa De CompensaciÃ³n Y Beneficios Para Trabajadores 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.
F242-174-000	Authorization for Deposit of Payments Used by pensioner to authorize L&I to deposit the pension payment to any designated financial institution.
F242-174-909	Authorization for Deposit of Payments - English/Spanish AUTORIZACIÃ“N PARA DEPÃ“SITOS DE PAGOS 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
F242-177-000	Direct Deposit Letter Used by the pensioner to learn about direct deposit. It accompanies the Authorization for Deposit of Payments (F242-174-000) form.
F242-177-999	DepÃ³sito Directo Used by the pensioner to learn about direct deposit. It accompanies the Authorization for Deposit of Payments- Spanish (F242-174-909) form.
F242-191-909	Notice to Employees -- If a Job Injury Occurs (English/Spanish) 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.
F242-243-000	Notice of Occupational Disease or Infection 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.
F242-352-000	Pension Benefits for Washington's Workers' Compensation Program Pamphlet/booklet: Answers the most common questions about pension benefits under Washingtonâ€™s workersâ€™ compensation system.
F242-352-999	Pension Benefits for Washington's Workers' Compensation Program - Spanish (Beneficios de PensiÃ³n para el Programa de CompensaciÃ³n para Trabajadores de Washington) Pamphlet/booklet: Answers the most common questions about pension benefits under Washingtonâ€™s workersâ€™ compensation system.
F242-363-909	How to Protest a Department of Labor and Industries Decision (English/Spanish) Fact sheet: Explains how an injured worker can protest decisions on his/her claim and gives deadlines for taking action.
F242-382-000	Letter of Intent for School Enrollment 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.
F242-382-999	Letter of Intent for School Enrollment - Spanish CARTA DE INTENCIÃ“N DE REGISTRO EN UNA ESCUELA Letter of Intent for School Enrollment - Spanish CARTA DE INTENCIÃ“N DE REGISTRO EN UNA ESCUELA
F242-385-000	Insurer Activity Prescription Form This form is used by health-care providers to communicate an injured worker's status, physical capacities, verification of inability to work (time-loss) and treatment plans. Employers and attorneys may not print or order these forms nor ask doctors to complete them. To print an APF, click on the title of the form in the box above. For more information about the form see the APF website at: www.ActivityRX.Lni.wa.gov
F242-387-000	Independent Medical Exam Doctor's Estimate of Physical Capabilities IME Doctorâ€™s Estimate of Physical Capacities: For use by independent examiners when asked to estimate physical capacities as part of an IME requested by the department.
F242-388-000	State Fund Claims Address Change Request 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.
F242-388-999	State Fund Claims Address Change Request - Spanish (Solicitud de Cambio de Domicilio para Reclamos del Fonda Estatal) 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.
F242-391-000	Application for Pension Benefits by Spouse or Children Used by a spouse or children to apply for pension survivor benefits if a total permanent disabled worker dies.
F242-391-999	Application for Pension Benefits by Spouse or Children - Spanish AplicaciÃ³n para beneficios de pensiÃ³n presentado por el cÃ³nyuge o hijos Used by a spouse or children to apply for pension survivor benefits if a total permanent disabled worker dies.
F242-393-000	Pension Benefits Questionnaire 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.
F242-393-999	Pension Benefits Questionnaire - Spanish CUESTIONARIO PARA BENEFICIOS DE PENSIÃ“N 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.
F242-395-000	Affidavit for Time Loss Compensation Benefits 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 F242-052-000 Worker Verification Form.
F242-395-999	F242-395-999 Affidavit_for_Time_Loss_Compensation_Benefits spanish DECLARACIÃ“N FIRMADA PARA COMPENSACIÃ“N DE TIEMPO PERDIDO F242-395-999 Affidavit_for_Time_Loss_Compensation_Benefits spanish DECLARACIÃ“N FIRMADA PARA COMPENSACIÃ“N 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.
F245-010-000	Statement for Compound Prescription 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.
F245-023-000	Performance Based Physical Capacities Evaluation Used by occupational and physical therapy providers as an optional reporting format for a Performance-based Physical Capacities Evaluation.
F245-030-000	Statement for Retraining and Job Modification Services 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.
F245-037-000	Case Transfer Card Used by injured worker to notify claim manager and request authorization to transfer care to a different doctor.
F245-037-999	Case Transfer Card (Spanish) Tarjeta para transferencia de caso Used by injured worker to notify claim manager and request authorization to transfer care to a different doctor.
F245-043-000	REFUND NOTIFICATION Refunding Money to L&I to correct your account? Used to Refund Money to L&I to correct your account REFUND NOTIFICATION
F245-046-000	Provider Account Application - Independent Medical Examiner (IME) In order to do independent medical exams a provider must obtain a provider account number with L&I. This packet includes the application and agreement with instructions, IME Provider Exam sites form (F245-047-000) and Request for Taxpayer ID and Certification - Form W-9 (F248-036-000) (8 pages).
F245-047-000	Independent Medical Examination (IME) Provider Exam Sites List the locations where the doctor does independent medical exams on a regular basis.
F245-049-000	Hearing Services Worker Information This is a list of the rights and conditions when an injured worker applies for hearing aids.
F245-050-000	Termination of Agreement (Rescission) To be filled out by the injured worker who wants to return hearing aids.
F245-051-000	Approved Independent Medical Examiner (IME) Update To update or correct the IME's contact, availability, qualificaitons and/or exam sites.
F245-052-000	Resource Utilization Group (Rug) Residential Care Services for L&I injured Workers Filled out by the provider when they treat an injured worker. See web links below for: Latest payment amounts, Updates and corrections, and Review payment policy.
F245-053-000	Independent Medical Exam Comments Used by the injured worker to provide comments to L&I about their recent medical exam by an IME.
F245-053-999	Comentarios Sobre el ExÃ¡men MÃ©dico Independente Used by the injured worker to provide comments to L&I about their recent medical exam by an IME.
F245-055-000	Submission of Provider Credentials for Interpretive Services Used to apply as a interpretive service provider and to show what language(s) you hold credentials for. F248-011-000 Provider Application and Notice is added to this form.
F245-056-000	Interpretive Services Appointment Record Used when an interpreter is appointed to interpret for an injured worker during their medical visits.
F245-057-000	Frequently Asked Questions about Job Modifications 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.
F245-058-000	Independent Medical Exam Template Template used by a doctor during an independent medical exam.
F245-059-000	Physical Therapy / Occupational Therapy Progress Report to Claim Managers The physical / occupational therapist uses this report to identify the clinical goals and return to work objectives of the injured worker.
F245-072-000	Statement for Miscellaneous Services 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.
F245-072-999	Instructions in Spanish for completing the form F245-072-000 Statement for Miscellaneous Services Instructions in Spanish for completing the form F245-072-000 Statement for Miscellaneous Services
F245-094-034	L&I Toolkit for Providers and Billing CD: Includes informational materials for new providers. Also contains the rules and policies for reimbursing medical services and lists maximum fees. This CD was previously titled Medical Aid Rules and Fee Schedules. To access the fee schedules, see the "Fee Schedules" Web page listed on the full description page for this publication.
F245-100-000	Statement for Pharmacy Services 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.
F245-127-000	CMS 1500 (formerly L&I Health Insurance Claim form) Used by providers to be reimbursed for services. It is NOT for use by injured workers to submit a claim to L&I.
F245-145-000	Travel Reimbursement Request Injured workers use this form to request reimbursement for travel expenses used to receive treatment, retraining and/or vocational services. These forms will be accepted by L&I. They may not be accepted by all Medical Bill Processors due to lack of a barcode.
F245-145-999	Travel Reimbursement Request Spanish (Solicitud para el reembolso de gastos de viaje) Injured workers use this form to request reimbursement for travel expenses used to receive treatment, retraining and/or vocational services.
F245-183-000	Providers Request for Adjustment Providers use this to report total overpayment, partial overpayment and/or underpayment by L&I. These forms will be accepted by L&I. They may not be accepted by all Medical Bill Processors due to lack of a barcode.
F245-224-000	Your Independent Medical Exam 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.
F245-224-999	Your Independent Medical Exam - Spanish (Su ExÃ¡men MÃ©dico Independiente) 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.
F245-299-000	Consultation Referral The attending doctor refers an injured worker for consultation for clinical issues, 120 day consultation and/or closing, etc.
F245-340-000	Labor and Industries Prosthetic Device Request Form Labor and Industries Prosthetic Device Request Form
F245-346-000	Job Modification Assistance Application 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.
F245-350-000	Pre-Job Accommodation Assistance Application For use by a therapist or vocational provider to request job modification for an injured worker before the injured workers is employed, possibly in a retraining program. This may involve tools and equipment that is purchased through L&I.
F245-351-000	Vocational Training Plan Ownership Agreement for Tools and Equipment Injured worker agrees to the ownership terms of the tools and/or equipment purchased as part of their training plan by L&I.
F245-353-000	1st 52 Week Period Plan Time Encumbrance 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.
F245-354-000	1st 52 Week Period Training Plan Cost Encumbrance To record the training plan costs for the first 52 weeks. For use only with plans approved before 1/1/2008. For plans approved after 1/1/2008, use F245-374-000.
F245-355-000	1st 52 Week Period Board & Room Cost Encumbrance 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.
F245-356-000	2nd 52 Week Period Plan Time Encumbrance 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.
F245-357-000	2nd 52 Week Period Training Plan Cost Encumbrance 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.
F245-358-000	2nd 52 Week Period Board & Room Cost Encumbrance 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.
F245-359-000	Opioid Progress Report Supplement: Chronic, Noncancer Pain 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.
F245-360-000	1st 52 Week Period Transportation Cost Encumbrance 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.
F245-361-000	2nd 52 Week Period Transportation Cost Encumbrance 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.
F245-365-000	Provider Accounts Change Form Providers use this form to notify L&I of a change of their business address, billing address and account termination. Also has info on how to notify L&I on a tax ID (EIN) number change, tax ID address change and/or name change.
F245-367-000	UB04 HCFA 1450 Used by hospitals to bill L&I for inpatient/outpatient services. This version includes NPI number.
F245-369-000	It's Good Business to Do Business with L&I Pamphlet: Explains the importance of quality health care in the treatment of injured workers. Describes the services L&I offers health-care providers who treat injured workers, including provider account representatives who can answer questions and assist with complex billing issues.
F245-372-000	Housing and Board Cost Encumbrance 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.
F245-374-000	Training Plan Cost Encumbrance 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.
F245-375-000	Transportation Cost Encumbrance 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.
F245-376-000	Plan Time Encumbrance 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.
F245-377-000	Long Term Care Assessment Tool You must mail or fax form. No emailed forms are accepted. This assessment tool is provided by L&I assessment to determine the medically appropriate level of care that will meet the Injured Workerâ€™s needs, abilities and safety in a residential facility. This assessment is not intended as a substitute for DSHS annual assessment & treatment plan, which is the sole financial responsibility of the facility.
F245-379-000	Provider Account Application Supplement & Notice for Orthopedic & Neurological Surgeon Quality Pilot Used by providers (Orthopedic, Neurological and Hand Surgeons) to participate in the Orthopedic and Neurological Surgeon Quality Pilot.
F245-380-000	Provider Account Application Supplement And Notice for PA-C and ARNP Orthopedic & Neurological Surgeon Quality Pilot Used by providers (PA-Cs, and ARNPs that work at a participating clinic) to participate in the Orthopedic and Neurological Surgeon Quality Pilot.
F245-381-000	Application for Self-Insurance Certification Supplement for the Orthopedic & Neurological Surgeon Quality Pilot Used by self-insured employers to participate in the Orthopedic & Neurological Surgeon Quality Pilot
F245-382-000	Notice of Independent Medical Exam No-Show or Late Cancellation Notice of Independent Medical Exam No-Show or Late Cancellation
F245-383-000	Independent Medical Examination Fax Cover Sheet Independent Medical Examination Fax Cover Sheet
F245-384-000	Hearing Aid Purchase and Repair Authorization Requests Hearing Aid Purchase and Repair Authorization Requests
F247-003-000	Department of Labor and Industries Home Modification Acknowledgement of Responsibilities 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.
F248-011-000	Provider Account Application For providers to apply for a provider account number with L&I. Includes the Form W-9 Request for Taxpayer ID Number and Certification (F248-036-000). 10-2009 version is internet only, not printed.
F248-025-000	Mailing Addresses and Telephone Numbers 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.
F248-031-000	Electronic Billing Authorization To authorize L&I to accept electronically submitted bills for services provided to injured workers (3 pages).
F248-036-000	Request for Taxpayer ID - Form W-9 Provider Accounts Use this form to obtain your taxpayer ID number.
F248-040-000	Hotline Tips for Medical Services Providers Fact sheet: Provides tips to help medical service providers quickly obtain answers to claims and billing questions. Introduces L&I's Provider Hotline, Interactive Voice Response Message System and online Claim & Account Center.
F248-055-000	Occupational or Physical Therapy Treatment Authorization Fax Request Used by a therapy provider/clinic to request authorization for outpatient occupational or physical therapy services for L&I claims.
F248-100-000	General Provider Billing Manual Used by providers to bill L&I for reimbursement.
F248-160-000	Statement for Home Nursing Services Used to bill L&I for reimbursement of home nursing services.
F248-343-000	Payroll Service Provider - Quarterly Reporting Bulk Filing Enrollment Form 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.
F248-355-000	Power of Attorney for Electronic Remittance Advice Providers complete this form to authorize a clearinghouse or third party to receive the EDI 835 Electronic Remittance Advice file from L&I's Provider Express Billing (PEB).
F248-357-000	Massage Practitioner (LMP) Treatment Authorization FAX Request Used by a licensed massage practitioner/clinic to request authorization for outpatient massage therapy services for L&I claims.
F248-361-909	Provider Application and Notice for Spanish Speaking Providers Outside the United States- English/Spanish This form is to be used by Spanish speaking Medical Providers out side 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.This version is not the same as the English version, which is intended for use by Providers in the United States
F249-006-111	Third Party Recovery Worksheet Used by third party attorneys to calculate distribution of proposed settlements in third party claims.
F249-008-000	Third Party Action - State Fund 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.
F249-008-999	Injured by a Third Party? You Have Legal Options - Spanish (Â¿Lesionado por un tercero? Usted tiene opciones legales) 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.
F249-017-000	Application for Inclustion on List of Eligible Attorneys Used by attorneys to be included on the Workers' Compensation Special Assistant Attorney General Program eligible list for Third Party claims.
F249-021-000	Supplemental Agreement Third Party Pharmacy Provider This agreement is to define access, performance and legal requirements for third party pharmacy billers who submit bills to and receive payment from L&I on behalf of pharmacy providers. This agreement authorizes L&I to accept and remit monies due the Pharmacy using a third party pharmacy biller.
F250-003-000	Individual Retrospective Rating Plan Agreement Used by employers to set up an agreement between them and L&I authorizing their participation in retrospective rating.
F250-004-000	Group Retrospective Rating Agreement Used by organizations to set up an agreement with L&I authorizing their participation in retrospective rating.
F250-006-000	Retrospective Rating Pamphlet: Provides information about how employers can enroll in a Retrospective Rating program to lower claim costs and reduce workers' compensation experience factor.
F250-007-000	Application for Group - Retrospective Rating Used by organizations that want to form a retrospective rating group, or by established groups to modify their retro plan or maximum premium ratio.
F250-016-000	Application for Group Membership & Authorization for Release of Insurance Data 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.
F252-001-000	Medical Examiners' Handbook Book: A publication for independent medical examiners, attending doctors and consultants, this document contains guidelines, sample reports and billing procedures for preparing and conducting impairment ratings and IMEs in Washington's workers' compensation system. The publication also includes a feature to assist physicians in attaining three hours of Category 1 CME credit by completing the self-assessment test at the end of the handbook. See also Self-Assessment Exam at www.Lni.wa.gov/IPUB/252-001-000Exam.pdf. L&I and the authors have no financial interest or other relationship with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this document.
F252-004-000	Attending Doctor's Handbook Book: This handbook contains useful information to help providers who treat patients in the workers' compensation system. The publication also includes a feature to assist physicians in attaining three hours of Category 1 CME credit by completing the exam at the end of the handbook. L&I and the authors have no financial interest or other relationship with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this document.
F252-005-000	Chiropractic Physician's Guide Book: Describes the responsibilities of the attending chiropractic physician in preventing claims problems.
F252-006-000	Doctor's Worksheet for Rating Dorso-Lumbar & Lumbo-Sacral Impairment This worksheet is to help the attending physician perform impairment rating on their patients with permanent partial disability of the Dorso-Lumbar or Lumbo-Sacral spine.
F252-007-000	Hearing Impairment Calculation Worksheet Used by the attending doctor to determine hearing loss.
F252-010-000	Medical Treatment Guidelines This is an outdated book of medical treatment guidelines and is available for archival reference only. The current medical treatment guidelines can be found at http://www.lni.wa.gov/ClaimsIns/Providers/Treatment/TreatGuide/default.asp where each guideline has its own link and file.
F252-013-000	Medical Device Review Request This form is so L&I's Office of the Medical Director can evaluate medical device(s) that the attending physican wants to use to treat an injured worker.
F252-017-000	Vocational Providers Application and Notice Used to obtain a vocational provider account number with L&I. This form includes a copy of F248-036-000 "Request for Taxpayer ID number and Certification". (12 pages)
F252-021-000	Individual Vocational Provider Account Change Form To change an individual's (service provider's) name, add or delete referral categories, update certifications, leaving a firm, intern supervisor changes, and/or adding or deleting a branch for referrals.
F252-022-000	Firm Vocational Provider Account Change To change a firm's (payee provider's) branch address within the same service location, contact info, tax info, adding or deleting designee for your firm.
F252-027-000	Vocational Closing Report Routing Sheet Routing slip that accompanies the Vocational Services Closing Cover Sheet (F252-028-000) which is used to close vocational services to an injured worker.
F252-028-000	Vocational Services Closing Cover Sheet 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.
F252-029-000	Assessment Closing Report 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.
F252-032-000	Sample Self-Employment Agreement Sample of a letter a return to work person would use to assist L&I in determining whether services or funds should be authorized to assist them in becoming self-employed.
F252-033-000	Sample on-the-job Training Agreement Sample on-the-job Training Agreement
F252-035-000	Sample Job Offer Letter Sample of a job offer letter from a business to an injured employee.
F252-040-000	Employer's Job Description 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.
F252-051-000	Sample Format for Vocational Testing Report Used by vocational counselors to test an injuried worker's skills and abilities.
F252-052-000	Sample Format for Vocational Evaluation Testing Plan Used by vocational counselors to evaluate the testing plan of the injuried worker.
F252-056-000	Doctor's Worksheet for Rating Cervical and Cervico-Dorsal Impairment Doctor's Worksheet for Rating Cervical and Cervico-Dorsal Impairment
F252-060-000	Home Modification for Workers with Catastrophic Injuries Fact sheet: Answers questions about the home modification benefit in Washington State's workers' compensation program, who qualifies, what L&I can pay, and where to get more information.
F252-061-000	Home Modification for Workers with Catastrophic Injuries - Questions and Answers for Contractors Fact sheet: Answers questions about the home modification benefit in Washington State's workers' compensation program and the bid process for contractors interested in this work.
F252-070-000	Sample Physical Demands Job Analysis Used by vocational rehabilitation counselors (VRCs) to document the physical demands of jobs.
F262-009-000	Discrimination Complaint Employees who believe they have been discriminated against by their employer may use this form to file a complaint.
F262-009-999	Queja Por DiscriminaciÃ³n Used by employees who believe they have been discriminated against by their employer may use this form to file a complaint.
F262-013-000	Occupational Disease Employment History Hearing Loss 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.
F262-013-111	Occupational Disease Employment History Hearing Loss (Continuation) 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.
F262-016-000	Occupational Hearing Loss Questionnaire 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.
F262-016-999	Cuestionario Sobre Perdida Del Sentido Auditivo en el Trabajo 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.
F262-024-000	Claim Suppression Complaint An injured worker may submit this form if their employer has suppressed their right to file an injury claim.
F262-024-999	Queja por Suprimir un Reclamo - Spanish - Claim Suppression Complaint An injured worker may submit this form if their employer has suppressed their right to file an injury claim.
F262-032-000	Targeting Fraud and Abuse in Washington State's Workers' Compensation Program: 2008 Report to the Legislature Booklet/Pamphlet: Provides an overview of L&I's activities to deter and detect workers' compensation fraud and abuse by workers, employers and medical providers. Includes statistics on dollars collected and costs avoided.
F262-249-909	Workers' Compensation Discrimination-English/Spanish (DiscriminaciÃ³n porque se lesionÃ³ en su trabajo) Fact sheet: Explains workers' legal right to file a workplace injury claim and how to file a complaint if discrimination has occurred.
F262-251-000	Targeting Fraud and Abuse in Washington State's Worker's Compensation Program: 2005 Report to the Legislature Booklet/pamphlet: Provides an overview of L&I's activities to deter and detect workers' compensation fraud and abuse by workers, employers and medical providers. Includes statistics on dollars collected and costs avoided.
F262-262-000	Avoid Liability for Your Subcontractor's Unpaid Workers' Comp Premiums Fact sheet: Tells construction contractors how to protect themselves from liability for their subcontractor's unpaid workers' compensation premiums.
F262-262-999	Avoid Liability for Your Subcontractor's Unpaid Workers' Comp Premiums -Spanish (Las primas de compensaciÃ³n para trabajadores no pagadas por su subcontratista podrÃan ser su responsabilidad) Fact sheet: Tells construction contactors how to protect themselves from liability for their subcontractor's unpaid workers' compensation premiums.
F262-276-000	Targeting Fraud and Abuse in Washington State's Workers Compensation Program: 2006 Report to the Legislature Booklet/pamphlet: Provides an overview of L&I's activities to deter and detect workers' compensation fraud and abuse by workers, employers and medical providers. Includes statistics on dollars collected and costs avoided.
F262-279-000	Workers' Comp Fraud Hurts YOU Pamphlet: Explains the impacts of workers' comp fraud and L&I's efforts to prevent and find fraud by workers, employers, contractors, and medical providers.
F262-280-000	Targeting Fraud and Abuse in Washington State's Workers' Compensation Program: 2007 Report to the Legislature Booklet/Pamphlet: Provides an overview of L&I's activities to deter and detect workers' compensation fraud and abuse by workers, employers and medical providers. Includes statistics on dollars collected and costs avoided.
F280-007-000	Plan Development Quality Assurance Review Form 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.
F280-008-000	Assessment Eligible Quality Assurance Review Form 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.
F280-010-000	Intent to Hire Preferred Worker 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.
F280-011-000	Intent to Hire Preferred Worker with Developmental Disabilities 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.
F280-013-000	Plan Development Recommending Plan Approval Routing Sheet 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).
F280-014-000	Assessment Recommending Plan Development Eligible Routing Sheet 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).
F280-016-000	Accountability Agreement This form is for school training plans, must be signed by the worker and VRC and sent in along with your training plan to L&I for approval. For OJT retraining plans, please refer to form F280-029-000.
F280-016-999	Accountability Agreement - Spanish (Acuerdo de Responsabilidad This form must be signed by the worker and the VRC and sent in along with the retraining plan to L&I for approval.
F280-017-000	Assessing Your Ability to Work: Your Rights and Responsibilities 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.
F280-017-999	Assessing Your Ability to Work: Your Rights and Responsibilities -- Spanish (Evaluando su capacidad para trabajar: sus derechos y responsabilidades, Servicios de rehabilitaciÃ³n vocacional) 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.
F280-018-000	Plan Development: What Are My Rights & Responsibilities? 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.
F280-018-999	Plan Development: What Are My Rights & Responsibilities -- Spanish (Plan de desarrollo: Â¿CuÃ¡les son mis derechos y responsabilidades? Servicios de rehabilitaciÃ³n vocacional) 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.
F280-019-000	Carrying Out Your Vocational Plan: Your Rights and Responsibilities During Plan Implementation 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.
F280-019-999	Carrying Out your Vocational Plan: Your Rights and Responsibilities During Plan Implementation -- Spanish (Llevando a cabo su Plan vocacional: Sus derechos y responsabilidades durante el Plan de ImplementaciÃ³n, Servicios de rehabilitaciÃ³n vocacional) 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.
F280-021-000	Preferred Worker Program Pamphlet/booklet: Describes the Preferred Worker Program and the benefits employers receive when hiring a preferred workers. Iin general, these are workers whose work-related injury or occupational disease prevents them from returning to their old job.
F280-021-999	Preferred Worker Program-Spanish (Programa con incentivos para reemplear trabajadores lesionados) 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.
F280-022-000	Preferred Worker Employers Job Decsription 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.
F280-023-000	Request for Preferred Workers Status Used by vocational providers to apply for preferred worker status in behalf of an industrially injured worker.
F280-024-000	Option 2 Vocational Benefits Training Enrollment Application and Verification 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.
F280-024-909	Option 2 Vocational Benefits Training Enrollment Application and Verification/APLICACIÃ“N Y VERIFICACIÃ“N DEL REGISTRO PARA CAPACITACIÃ“N DE BENEFICIOS VOCACIONALES OPCIÃ“N 2 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.
F280-025-000	Request for Plan Development Extension (State Fund) For state fund use only. Use this form to request a "good cause" extension to the 90-day requirement during vocational plan development. Examples of good cause include, but are not limited to: - A death in the worker's immediate family. For purposes of determining good cause, immediate family is defined as spouse, domestic partner, child, sibling, parent or grandparent. - Delays caused by documented changes in the workerâ€™s medical ability to participate in plan development. - Information received by the vocational rehabilitation provider that impacts plan development and was not available when assessment services were provided. - Documented delay in receipt of requested information from a medical provider relevant to developing the vocational plan. - The impact of previously identified barriers to employment and/or retraining.
F280-029-000	On the Job Training Accountability Agreement This form is for OJT training plans, and must be signed by the worker and VRC then sent in along with your training plan to L&I for approval. For non-OJT retraining plans, please refer to form F280-016-000.
F280-029-999	OJT Accountability Agreement ACUERDO DE RESPONSABILIDAD DE LA CAPACITACIÃ“N DURANTE EL TRANSCURSO DEL TRABAJO (Para planes presentados desde 7/1/08 al 6/30/09) OJT Accountability Agreement in Spanish
F280-032-000	OJT Information Request and Recommendation form VRCs can use this form to request information on a specific on -the -job (OJT) training opportunity listed on L&I's website, or to recommend an OJT training opportunity.
F280-033-000	Are You an Employer Who Can Provide On-the-Job Training? Fact sheet: Explains how employers play an important role in helping injured or ill workers return to meaningful employment and a productive life by offering on-the-job training opportunities.
F280-036-000	Option 2: What You Need to Know, Vocational Rehabilitation Services Booklet: Explains what happens when an individual selects "Option 2" and choose not to participate in the approved training plan.
F280-038-000	Vocational Questionnaire/Work History Vocational Questionnaire/Work History for use by Vocational Providers serving injured workers.
F280-039-000	On-The-Job Training (OJT) Worksheet for Vocational Providers On-The-Job Training (OJT) Worksheet for Vocational Providers
F413-007-000	Application for Asbestos Contractor Certification Contractors use this form to apply to be a certified asbestos contractor in Washington state.
F413-012-000	Chemical Hazard Communication: Helpful information for employers 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.
F413-012-555	Chemical Hazard Communication: Helpful information for employers (Vietnamese) 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.
F413-012-777	Chemical Hazard Communication: Helpful information for employers (Korean) 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.
F413-012-888	Chemical Hazard Communication: Helpful information for employers (Chinese) 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.
F413-012-999	ComunicaciÃ³n sobre Peligros QuÃmicos: InformaciÃ³n Ãºtil para los empleadores 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.
F413-014-909	Workers' Guide to Hazardous Chemicals: Understanding the Right-to-Know Law-English/Spanish (GuÃa del trabajador para el uso de quÃmicos peligrosos: Comprendiendo la Ley del derecho a saber) 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.
F413-024-555	Your Body, Your Job: Preventing Carpal Tunnel Syndrome and Other Upper Extremity Musculoskeletal Disorders (Vietnamese) 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.
F413-024-999	Su cuerpo, su empleo: PrevenciÃ³n del SÃndrome del TÃºnel Carpiano y otras lesiones mÃºsculo esquelÃ©ticas de las extremidades superiores 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.
F413-025-000	Asbestos Abatement Project Notice of Intent and L&I DOSH Asbestos Program Notice is not required for any asbestos project involving less than forty-eight (48) square feet of surface area, or less than ten (10) linear feet of pipe unless the surface area of the pipe is greater than forty-eight (48) square feet. Get instructions to complete the form.
F413-045-000	Poison Oak Poster (English/Spanish) 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.
F413-047-000	Protecting Yourself and Your Workers from Poison Oak and Ivy (English/Spanish) 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.
F413-049-000	Working Safely with Asbestos in Brake and Clutch Linings Pamphlet/booklet: Reviews the health hazards of asbestos exposure, use of asbestos in brake and clutch linings, employer's responsibilities, how employees can protect themselves, employee rights, and where to get help with waste management.
F413-060-000	Your Lungs, Your Work, Your Life: What You Should Know about Work-related Asthma Pamphlet/booklet: Briefly reviews the symptoms and causes of work-related asthma and explains prevention and treatment approaches.
F413-060-444	Your Lungs, Your Work, Your Life: What You Should Know about Work-related Asthma (Russian) Pamphlet/booklet: Briefly reviews the symptoms and causes of work-related asthma and explains prevention and treatment approaches.
F413-060-999	Sus Pulmones Su trabajo Su vida: Lo que deberÃa saber acerca del asma ocupacional Pamphlet/booklet: Briefly reviews the symptoms and causes of work-related asthma and explains prevention and treatment approaches.
F413-062-000	Cholinesterase Monitoring Reimbursement Request Employers use this form to request reimbursement for the reasonable costs of training, travel, recordkeeping, and medical expenses for Cholinesterase Monitoring.
F413-064-000	Cholinesterase Blood Testing Choice Use this form to say whether or not you choose to have the Cholinesterase blood tests performed.
F413-064-999	ElecciÃ³n para Prueba de Sangre de Colinesterasa Use this form to say whether or not you choose to have the Cholinesterase blood tests performed.
F413-065-000	Cholinesterase Monitoring Handling Hours Report Employers must complete this form for the employee for each periodic/follow-up test and provide a copy to the health care provider.
F413-068-000	Application for Replacement of Lost or Stolen Asbestos Certification Card This application is for any certified asbestos worker or supervisor that has lost or had their card stolen.
F413-070-000	Cholinesterase Monitoring Health Care Provider Recommendations 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.
F413-070-999	Monitoreo de la Colinesterasa Recomendaciones del Proveedor Medico formulario muestra 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.
F413-075-000	Worker and Community Right-to-Know Program Fact sheet: Provides an overview of the Worker and Community Right-to-Know (RTK) Program authorized by legislation in 1986. Explains the RTK fees, education on hazardous substances that the fees support, who pays the fees and how they are calculated.
F414-021-000	Variance Application - IND S&H Use this form to apply for a variance for an allowed deviation from a specific safety or health standard when an employer substitutes measures which afford an equal degree of safety.
F414-074-034	Workplace Safety and Health Rules CD: Contains workplace safety and health rules for Washington State and links to policies and related laws. Also contains guides covering accident prevention programs (APP) and personal protective equipment (PPE). Note: Order CD or view rules online.
F416-011-000	Safety and Health Discrimination Complaint Use this form to file a complaint when you feel you've been discriminated against or discharged for reporting a workplace safety hazard.
F416-011-999	Queja De Discriminacion Sobre Salud Y Seguridad En El Lugar De Trabajo 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.
F416-016-000	Statement This form is predominately used in non-accident related types of inspections. Used to obtain statements from employees or other individuals whenever it is determined that it would be useful to adequately document an apparent violation.
F416-034-000	Application for Charter Boat Operators License Use this form to apply for an operators license of a charter vessel.
F416-036-000	Reduce Your Costs at No Cost Pamphlet: Introduces free workshops to help employers prevent workplace injuries and control workers' compensation costs. Includes course descriptions, where you can find current schedules, and how to register.
F416-042-000	Mobile Cranes/Derricks Supplemental Component Worksheet
F416-043-000	Mobile Cranes/Derricks Worksheet for Construction Industry Mobile Cranes/Derricks Worksheet for Construction Industry
F416-044-000	Tower Crane Worksheet for Construction Industry
F416-051-000	Cranes, Derricks or Material Handling Devices Worksheet for Maritime Industry Use this form for the inspection of cranes, derricks and materials handling devices on waterfront operations
F416-052-000	Bulk Cargo Spouts, Suckers and Similiar Equipment for Maritime Operations Use this form for the inspection of spouts, suckers and similar equipment on waterfront operations
F416-054-000	Notice of Deficiencies Use this form for noting any deficiencies of cranes, derricks, material handling devices, spouts, suckers and similar equipment.
F416-056-000	Physical Exam - Charter Boat Operators License This form is used by applicants applying for a charter boat operators license to have completed by a physician for an operators license
F416-058-000	Charter Vessel Inspection Two part form used for the applicant to complete a Certification of Inspection of a charter boat and the second part is used for the Maritime Specialist to perform the inspection of the charter boat.
F416-063-000	Applicatiion for Accreditation Cranes/Derrick and other Material Handling Devices This form is for an applicant to complete for Maritime or Construction Accreditation.
F416-081-444	Job Safety and Health Law poster (Russian) Poster: Required in English, recommended in Russian for work sites with Russian-speaking workers. Describes important parts of the Washington Industrial Safety and Health Act (WISHA), which provides for job safety and health of Washington employees. Get poster printing tips.
F416-081-777	Job Safety and Health Law poster (Korean) Poster: Required in English, recommended in Korean for work sites with Korean-speaking workers. Describes important parts of the Washington Industrial Safety and Health Act (WISHA), which provides for job safety and health of Washington employees. Get poster printing tips.
F416-081-909	Job Safety and Health Law-English/Spanish (Ley de seguridad y salud en el trabajo) 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.
F416-087-000	Application for Permit to Operate Radio System in Designated Area This form is used by the logging industry to apply for a permit to operate a radio signal system.
F416-093-000	Witness Statement Use this form only on accident investigations, fatalities and catastrophies. This form is used to obtain statements from the witness to the accident or personnel who did not witness the accident but have information regarding the incident.
F416-132-000	A Guide to WISHA Pamphlet/booklet: Provides an overview of the Washington Industrial Safety and Health Act (WISHA), worker and employer rights and responsibilities, and consultation and compliance services L&I provides. NOTE: Pages 4 and 8 and back cover updated March 2009 to reflect the change in hospitalization reporting requirement that took effect April 2008.
F416-132-999	A Guide to WISHA-Spanish (GuÃa de WISHA, el programa de seguridad y salud para el lugar de trabajo del estado de Washington) Pamphlet/booklet: Provides an overview of the Washington Industrial Safety and Health Act (WISHA), worker and employer rights and responsibilities, and consultation and compliance services L&I provides. NOTE: Pages 4 and 8 and back cover updated March 2009 to reflect the change in hospitalization reporting requirement that took effect April 2008.
F417-014-000	Logging Emergency Medical Plan (Logging Safety and Health Meetings) Use this two part form for employers to record work locations and emergency rescue info and for holding safety meetings for each new jobsite
F417-031-000	Forklift Safety Guide Book: Provides general information on kinds of forklifts, principles of physics that apply to forklifts, training requirements for forklift operators, basic operator safety rules, dangers of carbon monoxide, and safety while servicing a forklift.
F417-043-000	Guide to Crew Safety Meetings Pamphlet/booklet: Provides a succinct guide to conducting crew safety meetings for general industry and the construction industry. Includes a format for recording meeting minutes.
F417-048-000	Supervisor's Report of an Accident Supervisors use this form to document information from an accident or injury.
F417-049-000	Crew Leader Safety Meeting Use this form to document the minutes of your safety meetings.
F417-055-909	Quick Tips for Lifting-English/Spanish (Consejos breves para levantar cargas) Fact sheet: Provides 10 tips for safer lifting. Contains illustrations.
F417-061-000	Safety and Health Video Library Online: Lists more than 2500 videos (VHS and DVD formats) on topics pertaining to occupational safety and health - everything from forklift safety to workplace violence prevention. Just perfect for safety meetings or committees. Complete information for borrowing procedures and setting up a free video library account with L&I at this link.
F417-067-000	Safety & Health Program Assessment Worksheet For use by consultants to evaluate employers' accident prevention programs. Use this form for large employers (more than 50 employees).
F417-067-111	Safety & Health Program Assessment Worksheet For use by consultants to evaluate employers' accident prevention programs. Use for businesses with less than 50 employees).
F417-087-000	Safety Meeting Minutes 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
F417-092-000	Guidelines for Selecting Reserve Trees Book: Provides technical guidance on retaining reserve trees in concert with safe work practices and forest and wildlife management goals. Produced cooperatively by state and federal agencies and industry groups.
F417-102-000	Competent Person Evaluation - Fall Restraint & Fall Arrest The employer uses this checklist to determine the person they have designated as a competent person is competent within the description and intent of the fall restraint and fall arrest stanard.
F417-104-000	Competent Person Evaluation - Excavation & Trenching The employer uses this checklist to determine the person they have designated as a competent person is competent within the description and intent of the excavation and trenching standards.
F417-107-000	Fall Protection Work Plan Requirements This booklet defines the work plan requirements you must meet for fall protection.
F417-129-000	Lessons for Lifting & Moving Materials Book: Identifies work areas, tasks and procedures that place employees at risk of injury. Describes and illustrates methods that help reduce the risk of injury.
F417-133-000	Office Ergonomics: Practical solutions for a safer workplace Book: Provides information and tools to analyze office jobs, find problems and develop ergonomic solutions.
F417-140-000	Workplace Violence: Awareness and Prevention for Employers and Employees Book: Describes four types of workplace violence, outlines steps to minimize and prevent violent acts, and discusses potential risk factors and prevention techniques. Includes a sample program and reproducible forms.
F417-150-000	Accident Prevention Program Analysis This form is used to analyze accident prevention programs for your business. This is only available online.
F417-150-002	Accident Prevention Program Analysis (Continued) This continuation form is used to analyze accident prevention programs for your business.
F417-188-909	Employee Discrimination Protection (English/Spanish)/ ProtecciÃ³n Para Empleados Contra La DiscriminaciÃ³n 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.
F417-195-000	Pocket Guide to Caution Zone Jobs Pamphlet/booklet: This advisory pocket guide reviews 14 workpalce risk factors that can lead to soft tissue injuries such as back strain, tendinitis and carpal tunnel syndrome. Suggests ways to identify the risk factors. Lists helpful resources from L&I.
F417-196-000	Lumber Handling in Sawmills Book: Developed by mill workers, mill managers and L&I, this manual describes the risks of musculoskeletal injury in lumber-handling jobs. Identifies controls to reduce hazards,increase efficiency and reduce injuries.
F417-202-000	Forklift Training Facts Fact sheet: Provides answers to the most-often asked questions about forklift training. Includes a checklist that employer may use to document that employees have been trained and/or evaluated in the required topics.
F417-205-000	Borrower Agreement Form Safety and Health Video Library Borrower Agreement Form - To open an account and borrow videos, please fill out this form.
F417-206-000	Reservation Form Safety and Health Video Library Use this form to make reservations of safety and health videos.
F417-207-000	Personal Protective Equipment (PPE) Guide Book: This guide helps employers comply with the WISHA Personal Protective Equipment rules. It covers general personal protective equipment and PPE requirements used to protect the head, eyes and face, hand and arm, foot and leg, and body (torso) in most work environments.
F417-208-000	Fall Protection: Responding to Emergencies Book: This guide is for employers and for employees who work from exposed, elevated surfaces. It covers the following: what to do to prevent fall-related emergencies and how to respond promptly if a fall-related emergency occurs. Includes illustrations of aided-rescue equipment systems.
F417-209-000	Say Yes! To a Safe Workplace, to a Free Consultation 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.
F417-209-999	Say Yes! To a Safe Workplace, to a Free Consultation-Spanish (Â¡Diga SÃ! A un lugar de trabajo seguro, a una consulta gratis) 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.
F417-213-909	Jorge's New Job: Cholinesterase Testing in Washington State (English/Spanish) Pamphlet/booklet: Uses a story format with dialogue and photographs to explain the hazards of cholineserase-inhibiting pesticides, the state's monitoring program and the importance of using proper safety equipment when working with pesticides.
F417-214-000	Protect Yourself and Your Family from Lead Poisoning Pamphlet/booklet: Explains the risks of lead exposure for workers who work on outdoor steel structures, and harmful effects on workers and their families. It includes a poster about the importance of safe work practices and procedures.
F417-218-909	Heat-related Illness Education Card/Tarjeta de educaciÃ³n sobre enfermedades relacionadas con el calor (English/Spanish) 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.
F417-221-000	Voluntary Protection Program (VPP) Fact sheet: Provides an overview of the VPP, a program that recognizes occupational safety and health excellence. Identifies benefits and includes testimonials from companies awarded VPP status.
F417-222-000	Safety & Health Video Library & Resource Center Pamphlet: Introduces the center and available services. You can borrow safety training videos and DVDs and order workplace posters. Also contains contact information.
F417-224-000	Safety and Health Investment Projects (SHIP) Grant Program Pamphlet/booklet: Introduces the SHIP Grant Program and application process. Eligible grants will aim to prevent injuries and illnesses, save lives, and educate workers and employers about workplace hazards and safe workplace practices. Proposals submitted by applicants
F418-023-000	Application for Copies of Citation and Notice Used by an employee to apply for copies of citation and notices issued to their employer.
F418-031-000	Hazard Documentation Worksheet Hazard Documentation Worksheet for use by L&I compliance staff to describe, measure and comment on workplace hazards.
F418-052-000	Alleged Safety Or Health Hazards (DOSH Complaint Form) Employees use this form to report work place conditions which jeopardize workers safety and health.
F418-052-999	Presuntos Riesgos de Salud y Seguridad - Alleged Safety Or Health Hazards (DOSH Complaint Form) - Spanish Employees use this complaint form to report work place conditions which jeopardize workers safety and health.
F418-055-000	Construction Checklist - Safety Construction Checklist - Safety
F418-055-999	Construction Checklist - Safety - Spanish - Lista de verificaciÃ³n de seguridad en la construcciÃ³n Construction Checklist - Safety - Spanish - Lista de verificaciÃ³n de seguridad en la construcciÃ³n
F500-010-000	Application for Amusement Ride or Air Supported Structure Operating Permit To apply for a decal for an amusement ride or air supported structure.
F500-018-000	Application for Electrical Contractors License Application used to get an electrical contractors license
F500-019-000	Electrical/Telecommunications Contractor's Bond to the State of WA Used to show proof of a bond in the State of Washington.
F500-020-000	Electrical/Telecommunications Contractor Assignment of Savings Account This is used to assign ownership interest to a savings account that is held by L&I for one year after a contractor's license has expired or after the contractor ceases business in Washington State.
F500-025-000	Agency Requested Inspection Used by non-L&I agencies and jurisdictional authorities to request an inspection on an electrical harzard.
F500-032-000	Request for Duplicate License or Certificate To request a duplicate of your Washington state electrical license or certificate.
F500-039-111	Chapter 19.28 RCW - Electricians and Electrical Installations - (effective 06/06/2006) Simplified version of the Chapter 19.28 RCW - Electricians and Electrical Installations Rules
F500-039-222	Electrical Safety Standards,Administration, and Installation WAC 296-46B Electrical Safety Standards,Administration, and Installation WAC 296-46B
F500-043-000	Affidavit of Experience This affidavit is used to record the hours of a trainee's electrical experience with direct supervision under a Washington certified journeyman, master or specialty electrician.
F500-044-000	Request for Change of Address Used by electrical licensee to notify L&I of an address change.
F500-045-000	Administrator / Electrician / Master Electrician Certificate Renewal To renew your electrical certificate. Fee varies depending on renewal type.
F500-054-000	Application to Establish an Account and Access to L&I's Electrical Permit & Inspection System (EPIS) with L&I's Miscellaneous Accounts To request access to L&I's EPIS - Miscellaneous Accounts
F500-055-000	Application to Access L&I's Electrical Permit and Inspection System (EPIS) from SecureAccess Washington and Utilize Contractor Deposit Account via the Internet To establish a contractor deposit account by an electrical contactor or registered construction contractors who are legally required to purchase electrical work permits from L&I.
F500-062-000	Request to Perform Electrical Product Field Evaluation The approval of this request to perform field evaluations will depend on the submitters meeting all the requirements of RCW 19.28. All requests must be submitted to L&I in writing at least 2 working days (48 hrs) prior to the project inspection date.
F500-063-000	Electrical Installation Variance Application To apply for a variance which is an allowable deviation from specific requirements of a National Electrical Code section, or the WAC 296-46B where the proposed alternate methods will maintain equivalent safety.
F500-065-000	Application for Amusement Ride Inspector Certification Application to be certified as an amusement ride inspector.
F500-066-000	Affidavit for Amusement Rides Affidavit of experience to apply for cetification as a Amusement Ride Inspector.
F500-068-000	Electrical Education Course Application Used to get approval of a course as an electrical continuing education class. This application must be received by L&I at least 30 days before the course is offered.
F500-072-000	Reassignment of Savings Account or Time Deposit - Electrical Contractor A reassignment is permitted only when (1) the Electrical Contractor (assignor) changes the name of the business; (2) the Electrical Contractor transfers the funds to a new account; or (3) the financial institution changes the account number.
F500-074-000	Electrical Work Permit Refund Request To apply for an electrical work permit refund. Online only.
F500-076-000	Investigation Report To notify L&I on any electrical work that you think is illegal.
F500-077-000	Electrical / Telecommunication Contractor's License Renewal Notice This form is used to notify you that your license will expire and for you to use to renew your license.
F500-078-000	Electrical Work on Residential Property: What You Should Know Before Work Begins Fact Sheet: Explains to property owners the importance of electrical permits, inspections and approvals. An electrical permit is required for most new, remodel and maintenance electrical work.
F500-080-000	Account Deposit for Contractor's or Miscellaneous Account Holder's Used to deposit money into your L&I account (Electrical).
F500-087-000	Electrical Inspection Witness Statement Used to gather information from a person who was a witness to electrical work that is being investigated by L&I.
F500-088-000	Application for Master Electrician Certification Examination Use this form to apply for the master electrician exam.
F500-090-000	Electrical Continuing Education Instructor Application An application to receive approval from L&I to instruct electrical continuing education courses.
F500-093-000	Contractor Electrical Work Permit Application This application is used to apply for a valid electrical permit from L&I. 4 pages.
F500-094-000	Property Owner Electrical Work Permit Application This application is used to apply for a valid electrical permit. 5 pages.
F500-097-000	Applicaton for an E2- 0% Supervision Modified Electrical Training Certificate & Specialty Examination Covers 03A, 06B, 07A, 07B, 07C, 07D, 07E, and 10 specialty licenses.
F500-098-000	Application for Specialty Electrician Certificate Application and instructions for the specialty electrician certificate for 03A, 06B, 07A, 07B, 07C, 07D, 07E and 10. Eligibility granted through modified supervision requirements of RCW 19.28.191(1)(g)(ii)
F500-099-000	Application for a E3-75% Supervision Modified Electrical Training Certificate Required if 3A, 6B, 7A, 7B, 7C, 7D, 7E, or 10 and have not completed the modified training requirements to receive specialty electrician cerfitication.
F500-101-000	Application for Accreditation of Engineer to Approve Industrial Utilization Equipment Used by an Engineer to apply for accreditation by L&I to approve unlisted equipment.
F500-104-000	Application for Pump Installer Combination General Contractor Registration and Electrical Contractor License Used for creating combination electrical and plumbing contractors license
F500-109-000	Electrical Work on Commercial Property: What You Should Know Before Work Begins Fact Sheet: Explains to commercial property owners the importance of electrical permits, inspections and approvals. An electrical permit is required for most new, remodel and maintenance electrical work.
F500-110-000	Questions and Answers about Electrical Safety Fact Sheet: Answers questions about training and certification/licensing requirements for those who perform electrical installations, and electrical work that requires a permit and inspection.
F500-111-000	Before Electrical Sign Work Begins: What Electrical Sign Contractors and Electricians Should Know Fact Sheet: Explains work that is allowed and not allowed under (04) Sign Scope of Work and what electrical sign contractors and electricians should know before doing sign work. Also covers electrical Class B labels and electrical permits, inspections and fees.
F500-112-000	Class B Labels: What You Should Know Fact Sheet: Explains Class B label electrical work, scope and limitations, and provides general instructions for using Class B labels.
F500-113-000	Online Electrical Services: Tools for Property Owners, Contractors and Electricians Fact Sheet: Describes the online services available from L&I's Electrical Program, including URLs for different topics covered on the Web, how to sign up for the Electrical listserv (to receive updates by e-mail), and how to sign up for the monthly e-newsletter, also provided by e-mail.
F500-114-000	Electrical Program Contacts Fact Sheet: Provides information for requesting electrical inspections, including telephone numbers and locations of L&I offices that handle electrical inspections.
F500-115-000	Electrical Safety Tips for Your Home: Protect Your Family and Your Property Pamphlet/Booklet: Provides information to help consumers properly handle electrical equipment and appliances, know the required permits and inspections for electrical work, and verify licenses and certifications before having electrical work performed.
F500-116-000	Green Power Generation System Installation: What You Should Know Before Doing Any Electrical Work Fact sheet: Explains that an electrical permit and inspection are required for most new, remodel, and maintenance electrical work. Provides information specific to the installation of green power generation systems.
F500-117-000	How to Become a Certified Electrician: What You Need to Know about Certification in Washington State Fact sheet: Provides information about getting a trainee card and outlines the electrical training and experience required to be certified as an electrician in Washington State.
F503-008-000	Application for Telecommunications Contractor's License Application used to get an telecommunications contractors license.
F503-009-000	Change Assignment of Administrator/Master Certificate To assign or unassign your status as an administrator or master.
F620-012-000	Non-Compliance Report - Boiler & Pressure Vessel Inspection Used by L&I inspectors when a boiler or pressure vessel does not pass inspection. You can only mail or fax this form to L&I. E-mailed forms are NOT accepted.
F620-017-000	Board of Boiler Rules Interpretation and Revision Request Form Used to submit written requests for interpretations and revisions to the definitions, rules and regulations found in WAC 296-104. These must be submitted 45 days prior to the Board of Boiler Rules Meeting date. To use this form, left click on the link and select SAVE TARGET AS and save to your desktop. Open in WORD, complete form, select PRINT, SEND TO, MAIL or DELIVERY DOCUMENT ONLY in care of Chief, Boiler Inspector.
F620-025-000	Operating Boilers Safely Fact sheet: Explains what you need to know to keep your boilers and pressure vessels operating safety. Provides an overview of inspection requirements, frequency and fees.
F620-027-000	Shop and Field Inspection Report Used by L&I inspectors when they inspect boilers.
F620-032-000	Boiler / Pressure Vessel Installation or Reinstallation Permit Click on the link at the top of the form to get instructions. This form is filled out by the installer, contractor and/or owner who wants to install or reinstall a boiler. 1 permit per object. E-mailed forms are preferred method of submission. To use this form, left click on the link and select SAVE TARGET AS and save to your desktop. Open in WORD, complete form, select PRINT, SEND TO, MAIL DOCUMENT AS ATTACHMENT to email form to Boilers.
F620-036-000	Monitoring Q.A./Q.C. Programs Record L&I Inspection report on the QA/QC manual of a company regarding boilers.
F620-037-000	Boiler Section QA/QC Monitoring Schedule The monitoring schedule of the QA/QC of boilers by L&I inspectors and notes if in-compliance or not in compliance.
F620-040-000	Application for Certificate of Competency as an Inspector of Pressure Retaining Items To apply for a certificate of competency as an Inspector of Pressure Retaining items. You can only mail or fax this form to L&I. E-mailed forms are not accepted. NOTE: Applications MUST be received no later than 30 days prior to the exam date Incomplete applications WILL NOT be accepted.
F620-041-000	Boiler/Pressure Vessel Clearance Variance Request To request a clearance variance on a boiler or pressure vessel. You can only mail or fax this form to L&I. E-mailed forms are not accepted.
F620-042-000	Rental Boiler Operating Permit - Good at this Location Only To request a permit to use a rental boiler at one location only.
F620-043-000	Historical Boilers Inspection Guideline Inspection sheet for boiler inspectors. 4 pages.
F620-044-000	Incident Report Boiler or Pressure Vessel Used for the reporting of incident with boilers or a pressure vessels.
F620-048-000	Keep Your Water Heater Safe Pamphlet/booklet: Describes the process for conducting an annual safety test of a residential water heater. Includes illustrations.
F620-050-000	Pre-Inspection Checklist for Hot Water Heating or Hot Water Supply Boilers Checklist which reflects the most common violations encountered by Field Inspectors. This checklist should be gone through prior to requesting inspection of Hot Water Heating or Hot Water Supply Boilers
F620-051-000	Pre-Inspection Checklist for Potable Water Heaters - HLW Checklist which reflects the most common violations found by Field Inspectors. This checklist should be gone through prior to calling for an inspection of Potable Water Heaters-HLW
F620-052-000	Pre-Inspection Checklist for Low Pressure Steam Boilers Checklist which reflects the most common violations found by Field Inspectors. This checklist should be gone through prior to calling for an inspection of Low Pressure Steam Boilers
F620-053-000	Pre-Inspection Checklist for High Pressure Boilers Checklist which reflects the most common violations found by Field Inspectors. This checklist should be gone through prior to calling for an inspection of High Pressure Boilers
F620-054-000	Boiler Inspector's Ride Along Audit Checklist Checklist used during a Boiler Inspector's Ride Along to determine if proper procedures are being followed.
F620-055-000	Board of Boiler Rules Extension of Inspection Frequency Request Form Board of Boiler Rules Extension of Inspection Frequency Request Form
F620-056-000	Chief Inspector Clarification and Interpretation Request Form Chief Inspector Clarification and Interpretation Request Form
F620-057-000	Board of Boiler Rules Washington State Specials Request Form Board of Boiler Rules Washington State Specials Request Form
F621-001-000	Construction Elevator Installation Application and Inpection Data Report Used by companies to apply for an Construction Elevator (Hoist) at a job site. One application per car and companies need to contact the Elevator Section for the appropriate installation and operating fee.
F621-005-000	Installation Application for Elevators Used for installation application for elevators (new, renewals, and alterations)
F621-046-000	Test Log for Periodic Inspections & Tests for Hydraulic Elevators ASME A17.1 requires periodic tests on various types of elevator equipment. This form is used as documentation to test hydraulic elevators.
F621-047-000	Test Log for Periodic Inspections & Tests for Traction Elevators ASME A17.1 requires periodic tests on various types of elevator equipment. This form is used as doucmentation to test traction elevators.
F621-048-000	Elevator Installation Variance Application Property owner or elevator company can apply for a variance to install an elevator. 4 pages.
F621-050-000	Elevator Information Update This form is required by L&I before they can process any changes to the ownership, physical or mailing address.
F621-051-000	Elevator Five-Year Safety Test Report This report is used by L&I for its five-year safety inspection of an elevator.
F621-052-000	Hydraulic Overpressure Test To be submitted when a valve is changed or a seal is broken.
F621-053-000	Extension Request This form is to request a time extension from an unforeseen circumstances for overdue corrections for conveyances.
F621-055-000	Test of Escalator Safety Devices A licensed elevator mechanic shall perform this test once a year and mail a copy to L&I.
F621-056-000	Conveyance Installation Approval by Building Official Used by the installer to notify L&I that a conveyance is proposed for installation in a buildiing.
F621-057-000	Elevator/General/Specialty Contractor Responsibility on New Installations Checklist for the elevator company/contractor to complete before the call L&I for an elevator inspection.
F621-063-000	Owner Requested Red Tag Form Used by the owner for red tagging a unit that is to be placed or to remain out of service.
F621-065-000	Request for Duplicate Elevator Certificate Used to request a duplicate elevator license or a duplicate operating permit for a conveyance.
F621-066-000	Elevator Refund Request To request a refund of the fee paid for an elevator permit.
F621-067-000	Application for Licensure as an Elevator Mechanic This is an application for certification as an Elevator Mechanic and is NOT a license to perform work. A contractor's license is still required by L&I.
F621-068-000	Temporary Licensed Elevator Mechanic This temporary license is limited to the mechanical and electrical operation, construction, installation, alteration, maintenance, inspection, relocation and repair of conveyances.
F621-069-000	Licensed Elevator Contractor (LC) Operation Contractors who install, construct, repair, alter or maintain elevators need to be licensed by the Elevator Program through L&I and with L&I's contractor registration program.
F621-070-000	License Requirements for Elevator Mechanics and Contractors Fact sheet: Explains licensing and testing requirements for mechanics who work on elevators and for contractors who install, repair or maintain elevators.
F621-077-000	Elevator Continuing Education Course Application This is used to apply for approval of elevator related continuing education courses.
F621-078-000	Elevator Continuing Education Instructor Application Application to become an instructor for elevator related courses.
F621-080-000	Renewal of Elevator Mechanic License Used by elevator mechanics to renew their license if they do not want to use the on-line "Get or Renew a License".
F621-082-000	Renewal of Contractor Elevator License Used by Elevator Companies to renew their Contractor License.
F621-084-000	How to Ride Safely on Elevators, Escalators and Moving Walks Pamphlet/booklet: Provides safety tips and interesting facts to promote safe use of elevators, escalators and moving walks.
F621-086-000	Change/Update Elevator Company Primary Point of Contact Used by the Elevator Section only to Change and/or Update the Primary Point of Contact for Elevator Companies
F621-094-000	APPLICATION TO ACCESS L& Iâ€™S ELECTRONIC PERMIT & INSPECTION SYSTEM (EPIS) FROM SECUREACCESS WASHINGTON AND UTILIZE CONTRACTOR DEPOSIT ACCOUNT VIA THE INTERNET
F621-095-000	Change Assignment of Primary Point of Contact Change Assignment of Primary Point of Contact
F621-098-000	ELEVATOR ACCOUNT DEPOSIT FOR CONTRACTORâ€™S OR MISCELLANEOUS ACCOUNT HOLDERâ€™S ELEVATOR ACCOUNT DEPOSIT FOR CONTRACTORâ€™S OR MISCELLANEOUS ACCOUNT HOLDERâ€™S
F621-099-000	Request for Duplicate Elevator Mechanic License Request for Duplicate Elevator Mechanic License
F621-100-000	Elevator Mechanic and Elevator Temporary Mechanic Address/Mailing Information Update Elevator Mechanic and Elevator Temporary Mechanic Address/Mailing Information Update
F622-006-000	Plan Approval Request - Recreational Vehicles and Recreational Park Trailers Plans to build recreational vehicles or park trailers need approval from L&I. This form is used as part of the approval process.
F622-011-000	Alteration Fire Safety Pre-Inspection Checklist Checklist for homeowners on how to upgrade their pre-HUD homes to approach the HUD standards in the area of fire safety.
F622-011-999	Alteration Fire Safety Pre-Inspection Checklist -Spanish Checklist for homeowners on how to upgrade their pre-HUD homes to approach the HUD standards in the area of fire safety.
F622-013-000	Electric / Gas Conversion Pre-Inspection Checklist This checklist is generic in content and may not include all requirements for your particular installation. The manufacturer's installation instruction must be adhered to and available to the inspector at the time of the inspection.
F622-014-000	Air Conditioner / Heat Pump Pre-Inspection Checklist This checklist is designed to be generic in content and may not include all requirements for your particular installation.
F622-015-000	Wood / Pellet Stove / Fireplace Pre-Inspection Checklist This checklist is designed to be generic in content and may not include all requirements for your particular installation.
F622-021-000	Application for State Plan Insignia for Recreational Vehicles and Recreational Park Trailers To apply for an insignia for a recreational vehicle.
F622-021-111	Insignia Continuation Sheet Recreational Vehicles and Park Trailers Continuation sheet to apply for an insignia.
F622-035-000	Plan Approval Request - Conversion Vendor / Medical Units Used in requesting a plan approval for Conversion Vendor or Medical Unit factory-assembled structures.
F622-036-000	Factory Assembled Structures Alteration Application Used by a homeowner or contactor to request a field inspection for an alteration to a manufactured or mobile home.
F622-038-000	Low Voltage Fire / Intrusion Alarm Checklist This checklist is designed to be generic in content and may not include all requirements for your particular installation.
F622-039-000	Alteration Re-Roofing for Low Slope Roofing Checklist used by the contractor when altering a low slope roof.
F622-040-000	Flood Damaged Manufactured Home Checklist Checklist on how to repair a flood damaged manufactured home. After the contractor has done all that is required by the checklist they call L&I for an inspection.
F622-043-000	Is it a Manufactured / Mobile Home? If your home has any of the items in this document, it is a manufactured / mobile home and requires inspections for all alterations by L&I's Factory Assembled Structures Section.
F622-044-000	Steel or Wrought-Iron Gas Line Pre-Inspection Checklist This checklist is used by the contractor when installing steel or wrought-iron gas line. Be sure you can answer YES to all questions before calling L&I for an inspection.
F622-045-000	Gas Room Heaters Pre-Inspection Checklist This checklist is used by the contractor when installing gas room heaters. Be sure you can answer YES to all questions before calling L&I for an inspection.
F622-046-000	Copper Tubing Gas Line Pre-Inspection Checklist This checklist is used by the contractor when installing gas lines with copper tubing. Be sure you can answer YES to all questions before calling L&I for an inspection.
F622-048-000	Gas Piping Test Affidavit You fill out, print and make a copy of this form on your company's letterhead. This affidavit must be available for the L&I inspector when the inspection is made.
F622-049-000	Your Manufactured / Mobile Home 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.
F622-049-999	Your Manufactured/Mobile Home-Spanish (Casas prefabricadas y mÃ³viles: Lo que los dueÃ±os de casas y contratistas deben saber al modificar una vivienda) 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.
F622-053-000	Alteration Polybutylene Re-Pipe Pre-Inspection Checklist This checklist is used by the contractor when altering a polybutylene re-pipe. Be sure you can answer YES to all questions before calling L&I for an inspection.
F622-054-000	Homeowners Manufactured / Mobile Home Variance Request This variance request applies only to the installations performed by a previous owner and does not apply to any home during the warranty period.
F622-063-000	Decertification of Manufactured and Mobile Homes This document shows the steps to decertify a manufactured or mobile home.
F622-072-000	Vendor / Medical Conversion Units Pre-Inspection Checklist Pre-Inspection Checklist to assist vendor owners, manufacturers, and others on what they need to know to get their vendor/medical unit approved by Labor and Industries.
F622-073-000	RCW 43.22.380 Exemptions Fire and Safety Checklist for Vendor/Medical Conversion Units Generic Checklist to determine if the particular installation includes all requirements prior to calling for an inspection. Must be able to answer YES to all questions prior to calling.
F622-075-000	Structural Inspection Request Questionnaire Structural Inspection Request Questionnaire
F622-076-000	Roof Affidavit Roof Affidavit
F623-006-000	Plan Approval Request - Factory Built Structures and Commercial Coaches A manufacturer of factory-built structures and/or commercial coaches uses this form to submit plans to L&I for review.
F623-013-000	Notification to Local Enforcement Agency L&I sends this form to notify the local agencies when a modular/moblie home is being built within a county or city limits.
F623-014-000	Application for Insignia for Factory Built Structures Manufacturer uses this form to apply for an official insignia for a manufactured / mobile home that has a plan approval number.
F623-016-000	Electrical Plan Approval Request - Factory Built Structures & Commercial Coaches Used by the manufacturer to request approval from L&I on an eletrical plan to build manufactured / mobile home(s) or commercial coaches.
F623-017-000	Panel Load Calculations Listing of Connected Loads and the Demand Loads. Used for all appliances that are fastened in place, permanently connected on specific circuit. Single Phase Panel Schedule and Three Phase Panel Scheule inlcude. Sample diagram included.
F623-019-000	Application for Insignia for Commercial Coaches Manufacturer uses this form to apply for an official insignia for commercial coaches that have a plan approval number.
F623-021-000	Application for Insignia Conversion Vendor/Medical Units Used to apply for an official insignia for conversion vendor or medical unit factory-assembled structures. See sample form for instructions about how to fill out the form correctly.
F623-025-000	Factory Assembled Structure Alteration Permit Refund Request A form to request a refund for a factory-assembled structure alteration permit.
F625-001-000	Application for Contractor Registration This is the form you would complete to register as a general contractor or specialty contractor. This is not in the warehouse. Please print off of the internet.
F625-003-000	Continuous Contractor's Surety Bond This form is used for the surety bond for construction contractors.
F625-008-000	Assignment of Account - WA State Banks Only Contractors may use this form to request an Assignment of Account in lieu of a surety bond. The amount of the surety bond would need to be placed into an account at a WA State Bank.
F625-011-000	Reassignment of Savings Account or Time Deposit - Construction Contractors 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.
F625-017-000	Facts About Construction Liens Fact sheet: Explains the basics of the construction lien law to help consumers protect themselves.
F625-029-000	Release of Lien by Contractor and Subcontractor(s) - Sample only This is a sample of a release of lien by a contractor or a subcontractor.
F625-030-000	Model Disclosure Statement Notice to Customer This disclosure statement is given to the consumer (customer) from the contractor showing they are registered in the state of Washington. The consumer (customer) signs this form as acknowledgement of receipt.
F625-033-000	Contractor Complaint Form Used by a home owner to file a complaint against a contractor.
F625-040-000	Construction Contractors: Get the Facts, Get Registered Pamphlet/booklet: Explains the steps to register as a construction contractor in Washington State.
F625-040-999	Construction Contractors: Get the Facts, Get Registered - Spanish (Contratistas de ConstrucciÃ³n: Obtenga los datos, regÃstrese) Pamphlet/booklet: Explains the steps to register as a construction contractor in Washington State.
F625-051-000	Subscription Request for Construction Contractor and Electrical Basic - CD This form is to be used to purchase the CD ROM of registered construction contractors, registered electrical contractors, plumbers and electricians.
F625-053-000	Filing Suit Against an Electrical Contractor Instructions for filing suit against an electrical contractor
F625-054-000	Construction Lien Notice This form is to be used by suppliers to notify homeowners that they have the ability to file a construction lien against their property if payment is not received.
F625-055-000	Construction Lien Summary General requirements that a lien claimant of a private construction project (not a commercial) must meet. This is intended show the general requirements for most lien claimants.
F625-061-000	Contractor Financial Information Used by the contractor to request L&I to release assignment of account that they used instead of a surety bond.
F625-066-000	Affidavit to Release Public Records This form is to request L&I to release public records in the contractors registration section.
F625-069-000	Registered Contractor Card This is a fillable version of the Registered Contractot Card
F625-077-000	Construction Contractor's Application for Worker's Compensation Account with No Worker Hours Used by employers with no employees or worker hours to report but need an open account for contract bidding process.
F625-082-000	Assignment of Account or Time Deposit for Insurance - Bodily Injury - WA State Banks Only 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.
F625-083-000	Assignment of Account or Time Deposit for Insurance - Property Damage - WA State Banks Only 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.
F625-084-000	Hiring a Contractor or Remodeler? What You Should Know Pamphlet/booklet: 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 contractors to register with L&I.
F625-084-999	Hiring a Contractor or Remodeler? What You Should Know-Spanish (Â¿Piensa contratar a un contratista de construcciÃ³n o remodelador?) 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.
F625-088-000	What to Do if You Want to File Suit Against Your Construction Contractor Fact sheet: Provides consumers with general information about the process for filing suit, and describes L&I's limited role in serving Summons & Complaint papers.
F625-094-000	Request for Archive Records - Contractor Registration This form is to request L&I to release archive records in the contractors registration section.
F625-097-000	Contractors: What if You Get a Notice of Infraction? Pamphlet/booklet: Tells contractors what their options are and what to do if they get a Notice of Infraction (a non-criminal violation).
F625-098-000	Washington Contractor's License Bond Validation Rider This rider is intended to be used in conjunction with a bond.
F625-099-000	Washington Contractor's License Bond Name Change Rider Used by the bond company to change the name of the contractor's business.
F625-100-000	Washington Contractor's License Bond License Number Change Rider Used by the bond company to change the contractor's business license number.
F625-101-000	Washington Contractor's License Bond Date Change Rider Used by the bond company to change the effective date of the contractor's bond.
F625-102-000	Washington Contractor's License Bond Bond Amount Rider Used by the bond company to amend the amount of the contractor's bond.
F625-103-000	Washington Contractor's License Bond Entity Change Rider Used by the bond company to show a change in the business structure of a contractor's business.
F625-104-000	Washington Contractor's License Bond Address Change Rider Used by the bond company to change the address of the contractor's business.
F625-107-000	Renewal Application for Contractor Registration Renewal Application for Contractor Registration
F625-108-000	Contractor Registration Request for Duplicate License or Address Change Contractor Registration Request for Duplicate License or Address Change
F625-109-000	Contractor Regsitration Officers/members Addendum Contractor Regsitration Officers/members Addendum
F626-001-000	Application for Electrician Examination Application and instructions for a Washington State electrician's certificate examination.
F626-048-000	Application / Renewal for an Electrical Training Certificate This the application for an Electrical Training Certificate or the renewal of. (This does NOT make you a registered apprentice).
F627-003-000	Application for Plumber Trainee Certificate This form is used to apply for a plumber trainee certificate.
F627-004-000	Affidavit of Experience - Plumbers This form is required to report plumber trainee's plumbing experience for credit towards journeyman or specialty status.
F627-008-000	Application for a Journeyman, Residential Specialty, Rec Plumbers or Med Gas Certificate This form is used to apply for plumber examination, reciprocal and medical gas endorsement.
F627-014-000	Request for Duplicate Certificate This form is used to request a replacement certificate for a plumber or plumber trainee.
F627-019-000	Journeyman, Specialty, Medical Gas Installer or Trainee Renewal This form is used to renew a plumber certification, plumber trainee or medical gas installer certification.
F627-022-000	Facts about State Certification for Plumbers Fact sheet: Explains plumber classifications, certification requirements, including required exams, and the application and renewal processes, including continuing education requirements.
F627-026-000	Facts about Medical Gas Piping Installer Endorsement Fact sheet: Explains training requirements and the endorsement process for medical gas piping installers.
F627-027-000	2009 and 2010 Plumbers Examination Dates and Locations This shows the current plumber examination dates and locations for the year 2009 and 2010. There are two separate files - the top file is the 2009 dates and the bottom file is the 2010 dates. The 2010 dates are not printed for the L&I warehouse yet. Please print a copy off of the internet.
F627-033-000	Application for Backflow Trainee Certificate This form is used to apply for a backflow trainee certificate.
F627-035-000	Application for Backflow Specialty Exam This form is used to apply for the backflow specialty examination.
F627-037-000	Plumber Continuing Education Course Application This form is used by the course sponser to submit continuing education courses for plumber certification.
F627-039-000	Plumber Request for Change of Address Plumber Request for Change of Address
F627-043-000	Affidavit of Continuity Affidavit of Continuity
F700-002-000	Parent / School Authorization for Employment of a Minor and Special Variance For legal guardians and school officials to approve a minor employee to work according to terms listed by the employer. This is NOT a work permit. Employers must obtain a minor work permit endorsement on their Master Business License where they employ workers under 18. The Special Variance for 16- and 17-year-olds to work up to 28 hours during the school weeks, is on page two of Parent/School Authorization form.
F700-007-000	Affidavit of Wages Paid - Public Works Contract - SAMPLE ONLY Sample copy with instructions: Used by a contractor, company or agency to show the wages paid to employees. This needs to be filed at the completion of a public works job/project. This PDF file will not print. Copies are available in the warehouse, 25 per pad.
F700-009-000	Record Keeping Provisions - Employment Standards This form is for employers to use to keep records on every employee.
F700-010-000	Operating Power Lawn and Yard-care Equipment: Safety for Teen Workers Fact sheet: Overview of safety practices, plus information on what equipment employees under 18 can and cannot operate. Provides resources on requirements for hearing protection and PPE (personal protective equipment).
F700-014-000	Application for Farm Labor Contractor License Used to apply or renew a license.
F700-022-000	Teens at Work: Facts for Employers, Parents and Teens 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.
F700-022-999	Adolescentes en el Trabajo: Los hechos para los empleadores, los padres y los adolescentes 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.
F700-024-000	Wage Transcription and Computation Sheet Employer uses this to show time worked and wages earned for an employee.
F700-027-999	Prevailing Wage Complaint and Instructions - Spanish - Instrucciones Para El Registro De Una Queja Sobre Los Derechos Laborales The Prevailing Wage form is now F700-146-000. This form is the Spanish version of the old Prevailing wage form. This will be replaced by F700-146-999 when the Spanish translation is completed. Ask L&I to conduct an investigation into a prevailing wage-related that affects one or more employees. See box 30 on the form to see what types of complaints are covered.
F700-029-000	Statement of Intent to Pay Prevailing Wages Public Works Contract SAMPLE ONLY Sample copy of the form that Contractors and Sub-contractors file a Statement of Intent to Pay Prevailing Wages public works contract upon accepting work on a public works project. This PDF file will not print. Copies are in the warehouse, order by the pad (25 a pad).
F700-032-000	Washington State Prevailing Wage Law Booklet: Contains the prevailing wage laws (RCWs) and rules (WACs) as well as plain language descriptions and contact information.
F700-041-000	Minimum Wage Law Booklet Covers Washington State Minimum Wage Law.
F700-046-000	Agreement - Farm Labor Contractors and Workers Employment wages and conditions agreement with Farm Labor Contractors and Workers
F700-046-999	Agreement - Farm Labor Contractors and Workers - Spanish - Acuerdo Entre Contratistas AgrÃcolas Y Trabajadores Employment wages and conditions agreement with Farm Labor Contractors and Workers
F700-051-000	Minimum Wage Law Exemptions Covers exemptions to Washington state minimum wage law.
F700-058-000	Employer Rights - Wages Paid Covers penalties for employer wage violations. Once stock runs out in warehouse, this form will be internet only.
F700-060-000	Farm Labor Contractor Assignment of Account or Time Deposit Farm Labor Contractor assignment of account or tme deposit for employee
F700-061-000	Farm Labor Contracting Rules Covers Farm Labor Contracting Rules for licensing and revocation, violations and legal procedures, and penalties.
F700-064-000	Payment of Wages - RCW 49.48.010 and 49.52.050 This is a copy of the law that pretains to the payment of wages to an employee when they stop working for an employer. The wages due to the employee for the pay period worked prior to leaving.
F700-065-000	Certified Project Payroll There are instructions in one PDF file, and a blank form that may be printed in the other PDF. The word document is saved in Microsoft 2003 format and is a fillable word form.
F700-066-000	Farm Labor Contractors Bond Notarized farm labor contractors bond coverage.
F700-067-909	Contracted Farm Workers Rights (English/Spanish) Covers workers rights when working for a farm labor contractor.
F700-074-909	Your Rights as a Worker in Washington State (English/Spanish) / Sus derechos como trabajador en el estado de Washington 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.
F700-076-000	Variance Application - For exceptions from specific rules governing employment of minors. Employer uses this application for requesting a variance to employment regulations for minors.
F700-079-000	Washington State OverTime Law Covers compensation for employees in Washington State working overime.
F700-085-000	Chapter 296-131 WAC Agriculture Employment Standard
F700-085-999	Agricultural Employment Standards - Chapter 296-131 WAC Spanish ESTÃNDARES DE TRABAJO AGRÃCOLA Agricultural Employment Standards - Chapter 296-131 WAC Spanish ESTÃNDARES DE TRABAJO AGRÃCOLA
F700-088-000	Farm Labor Contractor Registration Fact Sheet What Farm Labor Contractors need to know to Register for a License.
F700-089-000	Variance Application - Employment Standards Employer application request for a variance from employment standards for non minor employees.
F700-095-000	Minimum Wage Law - Truck Drivers Record keeping provisions and overtime for truck & bus drivers.
F700-096-909	Young Workers in Agriculture (English/Spanish) - Trabajadores jÃ³venes en la agricultura 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.
F700-097-000	Washington State Deduction Laws Deductions for current & terminated employees and employer liability for paying less than required.
F700-098-000	Internal Revenue Service Tax Compliance Certification Form to gain Internal Revenue Service Tax Compliance Certification for registered Farm Labor Contractors. Now includes IRS form 8821 Tax Information Authorization.
F700-099-000	Department of Employment Security Tax Compliance Certification Form to gain Department of Employment Security Tax Compliance Certification for registered Farm Labor Contractors.
F700-100-000	Department of Revenue Tax Compliance Certification Form to gain Department of Revenue Tax Compliance Certification for registered Farm Labor Contractors.
F700-102-909	Washington Minimum Wage Poster (English and Spanish) - Cartel del Salario MÃnimo de Washington Poster: Lists the minimum wage and basic facts about minimum wage. Get poster printing tips.
F700-103-909	Agricultural workers information line (English/Spanish) Card: Wallet card with a toll-free telephone number where agricultural workers can call to learn about their workplace rights.
F700-105-909	Your Daily Record of Hours Worked (English/Spanish) / Su Registro de Horas Trabajadas Pamphlet/booklet: A pocket-sized bilingual booklet to encourage agricultural workers to keep track of their daily work hours and earnings.
F700-109-000	Farm Labor Contractor Complaint Form Used to file a complaint against a Farm Labor Contractor, landowner, employer, or other where a possible infraction is concerned.
F700-109-999	Formulario De Queja En Contra De Un Contratista De Trabajores Agricolas (Farm Labor Contractor Complaint) Used to file a complaint against a Farm Labor Contractor, landowner, employer, or other where a possible infraction is concerned.
F700-112-000	Farm Labor Contractor Checklist Farm Labor Contractor's Checklist to ensure compliance.
F700-112-999	Lista De Comprobacion Para Un Contratista De Trabajores Agricolas (Farm Labor Contactor Checklist) Farm Labor Contractor's Checklist to ensure compliance.
F700-115-000	Are You an Employer or a Parent of a Teen Worker? Fact sheet: Presents facts and resources to help employers and parents keep teen workers safe on the job.
F700-115-999	Â¿Es Ud. un empleador o padre de un trabajador adolescente? Fact sheet: Presents facts and resources to help employers and parents keep teen workers safe on the job.
F700-117-000	Employing Minors Under Age 14 in Non-Agricultural Jobs Fact sheet: Explains when employers can and cannot employ minors under age 14 in non-agricultural jobs. Details the process for obtaining court permission when hiring minors under 14 is allowed.
F700-118-000	Employer Petition to The Court for Minor Work Permit Under Age 14 Petition to The Court for Minor Work Permit Under Age 14 by Employer.
F700-119-000	Court Form Granting Permission for Employment of Minors Form from Court Granting Permission for Employment of Minors to the employer.
F700-120-000	Application for Special Certificate to Employ at A Subminimum Wage Rate Employer Application for Special Certificate to Employ at A Subminimum Wage Rate.
F700-121-000	Application for House to House Sales Sales Employer Registration Certificiate Used by employers to register as employing minors who will be engaged in house-to-house sales, as required by WAC 296-125-120, with Labor and Industries.
F700-122-000	Application for Special Certificate to Employ A Vocationally Handicapped Worker at at Subprevailing Wage Rate Employer Application for Special Certificate to Employ A Vocationally Handicapped Worker at at Subprevailing
F700-124-000	Summary of Agricultural Employment Regulations and Farm Contractor Requirements This summary is on employment laws relating to the agricultural industry.
F700-125-000	Agricultural Employer Worksheet Used by agricultural employers to assist them in determining if they are following the state Agricultural Employment Standards and the Minimum Wage Act for their employees.
F700-126-000	L&I Agricultural Website and Telephone Resources This lists information about the agricultural information that can be found on the L&I website. It also has phone numbers to pertinent information.
F700-127-000	Farm Labor Employer Packet Packet of information for Farm Labor Employers. Packet has updated F700-124-000 form dated 6-2007. Packet includes other forms and RCW and WAC references.
F700-129-000	Interested Party Checklist for the Filing of Prevailing Wage Complaints Checklist used for the filing of Prevailing Wage Complaints by "Interested parties" ONLY.
F700-130-000	Sports Teams and Youth Workers Fact sheet: Explains the requirements for sports organizations that engage young people as volunteers or employees to referee, assist or work for the organizations. The focus is workers' compensation coverage and minor work rules.
F700-135-000	Seasonal Group Variance Application Used for Exceptions from the Hours of Work for Minors for Seasonal work. This form is a word document and can be completed electronically. If you have an electronic signature, you may use it on the form. You may save the form and send it as an attachment via email to the address at the top of the form, i.e., teensafety@Lni.wa.gov. If you do not have an electronic signature, complete the form, save it in your files, print it, sign it and fax or mail it to the address at the top of the form. Variance Application forms may be faxed to (360)Â 902-5300. If you would like the approved Variance Certificate faxed back to your business, please state so on your cover sheet.
F700-139-000	Safety Steps for Supervisors and Employees in Restaurants Fact Sheet: A useful summary of the responsibilities both employers and employees share for a safe workplace. This can be shared with new employees during their initial orientation.
F700-140-000	Restaurant Employee Safety Orientation Checklist Fact Sheet: Download this checklist to help with the safety orientation of new restaurant employees.
F700-141-000	Request for Public Records Prevailing Wage - Certified Payroll RCW 42.56 Used to request copies of Certified Payrolls for prevailing wage projects.
F700-142-000	Hiring Teens this Summer? 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.
F700-142-999	Hiring Teens this Summer?-Spanish (Â¿Piensa contratar adolescentes este verano?) 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.
F700-143-000	Affidavit of Wages Paid Addendum B List of Next Tier Subcontractors - Public Works Contract Copies of the 05-2008 version will be available in the warehouse later in July.
F700-144-000	Protected Leave Complaint For leave from work complaints: Download and complete a Protected Leave Complaint form (F700-144-000)
F700-145-909	Youth in Construction - English/Spanish (Adolescentes en construcciÃ³n) 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.
F700-146-000	Prevailing Wage Complaint and Instructions 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. This form used to be F700-027-000. The Spanish version F700-027-999 is still on the internet until this form is translated into Spanish. IMPORTANT The Worker Rights Complaint form is now F700-148-000
F700-147-000	Farm Labor Contractor Certified Payroll Farm Labor Contractor Certified Payroll
F700-148-000	Worker Rights Complaint Form This is the NEW Worker Rights Complaint Form. IMPORTANT: The Prevailing Wage Complaint form is now F700-146-000.
F700-148-999	Worker Rights Complaint Form - Spanish formulario de queja sobre los derechos laborales Worker Rights Complaint Form - Spanish formulario de queja sobre los derechos laborales. This form will be available in the warehouse the second week of October. Please print from the internet before that date.
F700-152-999	Plain Talk Summary of Prevailing Wage Laws: Understand Your Responsibilities and Rights When Performing Public Work (Resumen de las leyes de salario prevaleciente en lenguaje sencillo Entienda sus responsabilidades y derechos al hacer trabajos pÃºblicos) 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 Washington State Prevailing Wage Law (F700-032-000).
F800-006-909	Help for Crime Victims (English/Spanish) - Ayuda para Victimas de Crimen Pamphlet/booklet: Answers questions about Washington State's Crime Victims Compensation Program, who may be eligible for benefits and how to apply.
F800-025-000	Statement for Crime Victims Mental Health Services Used by the Crime Victims Compensation Program providers for reimbursement of Mental Health Services.
F800-031-000	Application to Reopen Crime Victim Claim for Aggravation of Condition 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.
F800-031-999	Application to Reopen Claim - Spanish AplicaciÃ³n Para Reabrir Un Reclamo Debido Al Empeoramiento De La CondiciÃ³n 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.
F800-041-000	Help for Crime Victims (large poster) 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".
F800-041-999	Help for Crime Victims (large poster) - Spanish (Ayuda para Victimas de Crimen) 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".
F800-042-000	Application for Benefits - Crime Victims 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.
F800-042-999	Instrucciones para la aplicaciÃ³n de beneficios - Instructions in Spanish for completing the Application for Crime Victims Benefits in English 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.
F800-049-000	Travel Reimbursement Request - Crime Victims If you are considered a victim of crime, use this form to track your travel expenses for medical, retraining or vocational services or for an independent medical exam. You should have approval from your claim manager before you travel.
F800-053-000	Master Level Counselor Provider Account Application for Crime Victims Master Level Counselor Provider Account Application for Crime Victims
F800-057-909	Request for Survivor Counseling Benefits (English/Spanish) Used by immediate family members of homicide victims to request mental health counseling.
F800-058-000	Statement for Pharmacy Services - Crime Victims Used by Crime Victims Compensation Program providers to bill for pharmacy services. Crime Victims Compensation Program providers are required to bill using this form.
F800-064-000	Provider's Request for Adjustment - Crime Victims 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.
F800-065-000	Request for Taxpayer Identification Number and Certification - Form W-9 Used by a provider assisting victims of crime to obtain a taxpayer ID number.
F800-070-000	Statement for Home Nursing Services - Crime Victims 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.
F800-074-000	Know What to Expect: How Recoveries and Settlements May Impact Your Crime Victim Claim Pamphlet and form: Explains third-party liability, recoveries and settlements. A crime victim or the Crime Victims Compensation Program may pursue monetary restitution from someone who caused or contributed to a crime victim's injury. Explains the purpose of the form and why individuals who file a crime victims claim are required to complete it.
F800-076-000	Statement for Crime Victim Miscellaneous Services 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.
F800-080-000	Crime Victims Compensation Program Initial Response and Assessment: Form I Used by the clinical provider to get approval to see a victim for six sessions or less. If more than six sessions, please complete Form II (F800-081-000).
F800-081-000	Crime Victims Compensation Program Initial Response and Assessment: Form II 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)
F800-082-000	Crime Victims Compensation Program Progress Note: Form III Used by the clinical provider to submit a request for preauthorization for payment of additional sessions.
F800-083-000	Crime Victims Compensation Program Treatment Report: Form IV Used by the clinical provider to request preauthorization for payment of additional sessions.
F800-084-000	Crime Victims Compensation Program Treatment Report: Form V Used by the clinical provider to get preauthorization for payment of additional sessions.
F800-085-000	Crime Victims Compensation Program Termination Report: Form VI 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.
F800-089-000	Provider Accounts Change Form for Crime Victims Compensation 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.
F800-095-000	Crime Victim's Compensation Claim for Pension by Dependents Used by dependents of a deceased Crime Victim to determine eligibility to receive pension benefits.
F800-095-999	Crime Victims Request for Pension by Dependents - Spanish Used by Spanish speaking dependents of deceased crime victims who are applying for pension benefits.
F800-098-000	Crime Victim Compensation Program Sexual Assault Exam Report A form used by physicians, hospitals and clinics to provide information and reporting to the Crime Victims Compensation Program.
F800-100-000	Billing Guidelines for Sexual Assault Examinations: Crime Victims Compensation Program Provides information health-care providers need to bill the Crime Victims Compensation Program for medical services.
F800-102-000	Helping Providers Understand the Crime Victims Compensation Program Fact sheet: Answers questions doctors and mental health counselors may have about the Crime Victims Compensation Program and billing for services. Also suggests steps these providers can take to speed up reimbursement.
F800-104-000	Help for Crime Victims (small poster) 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."
F800-104-999	Help for Crime Victims (small poster) - Spanish (Ayuda para Victimas de Crimen) 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."
F800-105-000	Mental Health Fee Schedule and Billing Guidelines Manual: This manual is for providers who bill the Crime Victims Compensation Program for mental health services for crime victims.
F800-107-000	Crime Victims Insurer Activity Prescription Form (APF) Crime Victims Insurer Activity Prescription Form (APF)
F800-110-000	Victim Verification Form For use by crime victims requesting time-loss compensation
F800-110-999	Crime Victim Worker Verification - Spanish FORMULARIO DE VERIFICACIÃ“N DE EMPLEO Crime Victim Worker Verification - Spanish FORMULARIO DE VERIFICACIÃ“N DE EMPLEO
F800-111-999	Crime Victim Pension Benefits Questionnaire Form for Crime Victims - CUESTIONARIO PARA BENEFICIOS DE PENSIÃ“N Crime Victim Pension Benefits Questionnaire Form for Crime Victims - CUESTIONARIO PARA BENEFICIOS
F800-112-000	Crime Victims Address Change Request Crime Victims Address Change Request
FSP0-900-001	Sticker - Emergency Information
FSP0-901-000	Safety Comes Thru Job Training A supervisor having a discussion with his crew. Get poster printing tips.
FSP0-903-000	Ten Safe Handling Hints for Knives Shows ten tips on handling a knife safely. Get poster printing tips.
FSP0-904-000	Preventing Slips and Falls Information on how to prevent slips and falls with your footwear, housekeeping and also some general awareness tips. Get poster printing tips.
FSP0-905-000	Fryer Safety Tips on deep frying safety. Get poster printing tips.
FSP0-906-000	Ten Steps for Avoiding Burns Tips on how to avoid burns while cooking. Get poster printing tips.
FSP0-907-000	Does This Ring a Bell? Wear Your Hard Hat Picture of a guy getting hit in the head with a large metal hook. Get poster printing tips.
FSP0-908-000	Stay Clear of Suspended Loads Pictures a guy under a suspended wooden carton. Get poster printing tips.
FSP0-912-000	No Shoring Can be a Grave Situation Picture of a front loader above and it's bucket scooping up dirt in a large hole with a worker also in the hole. Get poster printing tips.
FSP0-915-000	The Best Accident Insurance - To observe all safety regulations Picture of a guy with Saftey Policy and Rules in his hand. Get poster printing tips.
FSP0-918-000	Four Steps to Proper Lifting Pictures of a person lifting a large box correctly along with tips on how to correctly lift a large item safely. Get poster printing tips.
FSP0-919-000	Robberies and Abusive Customers: Tips for Preventing Injuries Tips on handling cash and how to have a safer restaurant or retail environment. Get poster printing tips.
FSP0-928-000	Caution: Hard Hat Area Visual reminder of the importance of wearing a hard hat. Get poster printing tips.
FSP0-928-999	PrecauciÃ³n: Obligatorio Usar Casco Picture of hard hats. Get poster printing tips.
FSP0-940-000	Always Wear Eye Protection Picture of a large eye with some content on when to use eye protection. Get poster printing tips.
FSP0-940-999	Siempre Use ProtecciÃ³n para los ojos Picture of a large eye with some content on when to use eye protection. Get poster printing tips.
FSP0-941-000	Always Wear Eye Protection Sticker: 7.25 inches X 4.25 inches.
FSP0-951-000	Ladder Safety Picture of a ladder with safety tips on the rungs. Get poster printing tips.
FSP0-954-000	Keys to Safety Picture of two keys with the words 'Skills' and Knowledge' on them. Get poster printing tips.
FSP0-963-000	Getting Killed is Easy Large words that say: Getting killed is easy. Staying alive is work. Get poster printing tips.
FSP0-963-999	Matarse es Fácil. Mantenerse vivo es trabajo. Large words that say: Getting killed is easy. Staying alive is work.
FSP0-972-000	Danger! Minimum Clearance for Counter Balance - Logging
FSP0-974-000	Danger! Minimum Clearance for Counter Balance - Construction Sticker: 30 inches long.
FSP0-978-000	Safe Ways - Fork Lift Safety Safety tips on using a fork lift. Get poster printing tips.
FSP0-993-000	Put this Guard Back Sticker: 8.5 inches X 3.5 inches
FSP0-993-001	Put this Guard Back Sticker: 5 1/2 inches X 2 1/8 inches
FSP0-993-991	Put this Guard Back (Spanish) Sticker: 5.5 inches X 2.15 inches
FSP0-993-999	Put this Guard Back (Spanish) Sticker: 8.5 inches X 3.5 inches
FSP1-000-000	Grinding Wheel - Prevent Accidents Sticker: No size available
FSP1-004-000	Report All Injuries Promptly Large words: Report All Injuries Promptly. Get poster printing tips.
FSP1-004-999	Reporte Todas Las Lesiones Inmediatamente Large words: Report All Injuries Promptly. Get poster printing tips.
FSP1-005-000	First Aid Sticker: No size available
FSP1-010-000	Well...My Daddy Wears 'Em Little boy wearing his daddy's hard hat, eye protection, gloves and boots. Get poster printing tips.
FSP1-012-000	Danger, Workers Above Picture of workers on a high rise. Get poster printing tips.
FSP1-012-999	Danger, Workers Above-Spanish (Peligro, Trabajadores en el nivel superior) Picture of workers on a high rise. Get poster printing tips.
FSP1-013-000	Danger, Construction Area Authorized Personnel Only Large words: Danger, Construction Area Authorized Personnel Only. Get poster printing tips.
FSP1-013-999	Peligro Ãrea en ConstrucciÃ³n Solamente Personas Authorizadas Large words: Peligro Ãrea en ConstrucciÃ³n Solamente Personas Authorizadas. Get poster printing tips.
FSP1-030-000	Danger Large lettering: DANGER. Get poster printing tips.
FSP1-030-999	Peligro Large lettering: PELIGRO
FSP1-051-000	Walk, Don't Run Timeless reminder to walk, don't run, showing a banana peel. Get poster printing tips.
FSP1-055-000	Watch Where You Step Large lettering: Watch Where You Step. Get poster printing tips.
FSP1-063-000	Know Your Lockout Tagout Safety Procedure Cartoon of a guy carrying a large lock and key with the words 'Know Your Lockout Tagout Safety Procedures'. Get poster printing tips.
FSP1-065-000	High Noise Area, Wear Hearing Protection Cartoon of a guy plugging his ears with his fingers while his hearing protection is wrapped around his neck with the words 'High Noise Area' above his head. Get poster printing tips.
FSP1-075-000	Use Your Safety Equipment Man working on a roof with fall protection, eye protection, work boots and the ladder is tied off. With words: Just Making Sure I Get Home Safely! Get poster printing tips.
FSP1-075-999	Use su equipo de protecciÃ³n (Spanish) - Use Your Safety Equipment Man working on a roof with fall protection, eye protection, work boots and the ladder is tied off. With words: Just Making Sure I Get Home Safely! Get poster printing tips.

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