For use by consultants to evaluate employers' accident prevention programs. Use this form for large employers (more than 50 employees).

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.

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.

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).

Your answers to these questions will be used to assist in evaluating your damages if a claim is made against a liable third party.

For use by consultants to evaluate employers' accident prevention programs. Use for businesses with less than 50 employees).