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Challenging Times Demand Our Best
Booklet: Describes how L&I is making changes, both big and small, to better serve our customers and operate efficiently. Three areas of focus are fighting fraud, putting customers first and cutting costs. Features stories about three customers L&I has helped.

Publicación
F101-095-000
 
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.



Formulario
F207-070-000

Otro(s) idioma(s):
Español
 
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.



Formulario
F212-034-000
 
Reporte Trimestral para la Industria de Tabla de Yeso

Usado por los empleadores de tabla de yeso como una guía para completar los informes trimestrales y suplementarios.  Esto incluye ejemplos para completar el formulario F212-050-000 y el F212-051-000.



Formulario
F212-224-999

Otro(s) idioma(s):
Inglés
 
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.



Formulario
F242-395-000

Otro(s) idioma(s):
Español
 
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) (10 pages). If you have questions, please email balk235@lni.wa.gov or call 360-902-6815.



Formulario
F245-046-000
 
Independent Medical Examination (IME) Provider Exam Sites

List the locations where the doctor does independent medical exams on a regular basis.



Formulario
F245-047-000
 
Approved Independent Medical Examiner (IME) Update
To update or correct the IME's contact, availability, qualificaitons and/or exam sites.

Formulario
F245-051-000
 
Plan Time Encumbrance
To record the work plan time. For use only with plans approved after 1/1/2008.

Formulario
F245-376-000
 
Interpreter Services for Injured Workers and Crime

Flier: Describes interpreter services available to injured workers and crime victims. Covers how to get an interpreter; who can interpret and get paid for it; and basics of interpreter's professional conduct.



Publicación
F245-412-000

Otro(s) idioma(s):
Español
 
Servicios de Intérprete para Trabajadores Lesionados y Víctimas de Crimen

Volante: Describe los servicios de intérprete disponible a los trabajadores lesionados y a las víctimas de crimen.  Incluye información de cómo obtener un intérprete; quién puede interpretar y recibir pago; y el concepto básico de conducta profesional del intérprete.



Publicación
F245-412-999

Otro(s) idioma(s):
Inglés
 
Cranes, Derricks and Material Handling Devices Worksheet for Maritime Industry

Use this form for the inspection of cranes, derricks and materials handling devices on waterfront operations



Formulario
F416-051-000
 
Bulk Cargo Spouts, Suckers, and Similar Equipment for Maritime Operations

Bulk Cargo Spouts, Suckers, and Similar Equipment for Maritime Operations



Formulario
F416-052-000
 
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.



Formulario
F500-072-000
 
An Annual Electrical Permits Saves Time and Money. Would it Work for You?

Flier: Describes when facility operators/owners qualify for an annual electrical permit.



Publicación
F500-123-000
 
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.



Formulario
F625-011-000
 
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.



Formulario
F625-082-000
 
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.



Formulario
F625-083-000
 
Farm Labor Contractor Assignment of Account or Time Deposit

Farm Labor Contractor assignment of account or tme deposit for employee



Formulario
F700-060-000
 
Washington State OverTime Law

Covers compensation for employees in Washington State working overime.



Publicación
F700-079-000
 
Help for Victims of Crime / Ayuda para víctimas de crimen (English/español)

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

Folleto: Responde preguntas sobre el Programa de Compensación para Víctimas de Crimen del estado de  Washington, quienes podrían tener derecho a recibir beneficios y cómo pueden aplicar. 

 



Publicación
F800-006-909
 
Statement for Crime Victims Mental Health Services

Used by the Crime Victims Compensation Program providers for reimbursement of Mental Health Services.



Formulario
F800-025-000
 
Application to Reopen Crime Victim Claim Due to Worsening of Condition

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



Formulario
F800-031-000

Otro(s) idioma(s):
Español
 
Help for Crime Victims (large poster)

Poster (11" X 17"): Highlights the Crime Victims Compensation Program and provides contact information. Intended for display in health-care, criminal-justice and social-service organizations. Can be downloaded and printed, or ordered from L&I. Smaller version is also available (8.5" X 11"). Get 11" X 17" poster printing tips.



Cartel
F800-041-000

Otro(s) idioma(s):
Español
 
Ayuda para víctimas de crimen (cartel grande)

Cartel:  Documento con las medidas 11 X 17 pulgadas. Resalta el Programa de Compensación para Víctimas de Crimen y proporciona información para comunicarse con el programa. La intención es ponerlo a la vista en clínicas, organizaciones judiciales y de servicios sociales. Puede descargarse e imprimirse o solicitarse de L&I.  Hay una versión disponible más pequeña (8.5 X 11 pulgadas).



Cartel
F800-041-999

Otro(s) idioma(s):
Inglés
 
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. The Spanish version of the instructions are online as F800-042-999.



Formulario
F800-042-000

Otro(s) idioma(s):
Español
Español
 
Instrucciones para: Solicitud para Beneficios para Víctimas de Crimen

Instrucciones en español para completar el formulario F800-042-000, Solicitud para beneficios para víctimas de crimen.  El formulario es utilizado por víctimas de crimen en el estado de Washington para recibir beneficios de tiempo perdido del trabajo, pérdida de apoyo económico, tratamiento médico y de salud mental.  Esta versión del 10 de diciembre está en Internet solamente.



Formulario
F800-042-999

Otro(s) idioma(s):
Inglés
 
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.



Formulario
F800-049-000
 
Master Level Counselor Provider Account Application for Crime Victims

Master Level Counselor Provider Account Application for Crime Victims



Formulario
F800-053-000
 
Crime Victims Statement for Pharmacy Services

Used by Crime Victims Compensation Program providers to bill for pharmacy services. Crime Victims Compensation Program providers are required to bill using this form.



Formulario
F800-058-000
 
Crime Victims Provider's Request for Adjustment

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.



Formulario
F800-064-000
 
Statewide Payee Registration and W-9 Form Crime Victims

Used by a provider assisting victims of crime to obtain a taxpayer ID number. Note: Register now for direct deposit available January 2013.



Formulario
F800-065-000
 
Crime Victims' Statement for Compound Prescription

Bill form for use by pharmacies and home infusion companies to submit compound drug charges for Crime Victims Compensation. This form is for drug charges only and is filled out by the pharmacist.



Formulario
F800-067-000
 
Crime Victims Statement for Home Nursing Services

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.



Formulario
F800-070-000
 
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.



Publicación
F800-074-000
 
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.



Formulario
F800-076-000
 
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).

Formulario
F800-080-000
 
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)



Formulario
F800-081-000
 
Crime Victims Compensation Program Progress Note: Form III

Used by the clinical provider to submit a request for preauthorization for payment of additional sessions.



Formulario
F800-082-000
 
Crime Victims Compensation Program Treatment Report: Form IV

Used by the clinical provider to request preauthorization for payment of additional sessions.



Formulario
F800-083-000
 
Crime Victims Compensation Program Treatment Report: Form V

Used by the clinical provider to get preauthorization for payment of additional sessions.



Formulario
F800-084-000
 
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.



Formulario
F800-085-000
 
Provider 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.



Formulario
F800-089-000
 
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.



Formulario
F800-098-000
 
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.



Manual
F800-100-000
 
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.

Publicación
F800-102-000
 
Help for Crime Victims (small poster)

Poster (8.5" X 11"): Highlights the Crime Victims Compensation Program and provides contact information. Intended for display in health-care, criminal-justice, and social-service organizations. Can be downloaded and printed, or ordered from L&I. Larger version is also available (11" X 17").



Cartel
F800-104-000

Otro(s) idioma(s):
Español
 
Ayuda para víctimas de crimen

Cartel:  Documento con las medidas 8.5 X 11 pulgadas.  Resalta el programa de compensación para víctimas de crimen y proporciona información para comunicarse con el programa. La intención es ponerlo a la vista en clínicas, organizaciones judiciales y de servicios sociales.  Puede descargarse e imprirse o solicitarse de L&I. Hay una versión disponible más grande (11 X 17 pulgadas).



Cartel
F800-104-999

Otro(s) idioma(s):
Inglés
 
Crime Victims Address Change Request

Crime Victims Address Change Request



Formulario
F800-112-000
 
Your Independent Medical Exam (IME): Crime Victims Compensation Program
Fact Sheet: Provides answers to commonly asked questions about independent medical exams (IMEs) and contact information. Includes a form for requesting travel-related reimbursement for attending an IME.

Publicación
F800-115-000
 
Crime Victims Direct Entry Billing Manual
Instructions for completing a Direct Entry bill to submit to the Crime Victims Compensation Program. Direct entry allows you to submit or adjust bills using a free online billing form through Provider Express Billing (PEB).

Manual
F800-118-000
 
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 Instruction (RSI).



Formulario
F100-509-000
 
An Employer's Intro to L&I

Info card: Provides information on the Employer's Intro to L&I workshop, including statewide schedule of workshops. Designed for employers and managers, the workshop covers a number of topics, including workers' compensation insurance, workplace safety, and overtime.



Publicación
F101-101-000
 
Pocket Guide to Worker Rights

Brochure: This guide is to help workers understand their rights in Washington State. It includes information about safety and health protection, minimum wage and overtime pay, prevailing wage, rest and meal breaks, sick leave, family leave, workers' compensation benefits and retaliation.



Publicación
F101-165-000
 
Need a Doctor?

Information card: Provides contact information for injured workers needing assistance in finding a health-care provider who will treat their occupational injury or disease. This PDF will print out an 8.5" X 11" sheet that has 12 copies of the card. Note: Disclaimer information on Page 2 may not line up accurately in two-sided printing.



Publicación
F160-006-000

Otro(s) idioma(s):
Español
 
Necesita un doctor?

Tarjeta de información: Proporciona información a los trabajadores lesionados sobre con quien comunicarse si necesitan ayuda para encontrar un proveedor de cuidado de la salud que pueda darle tratamiento para su lesión o enfermedad ocupacional.  Este documento PDF imprime una hoja “8.5x11” que tiene 12 copias de la tarjeta.  Aviso: La información del descargo de responsabilidad en la página 2 puede que no esté alineada correctamente con la impresión en ambos lados.



Publicación
F160-006-999

Otro(s) idioma(s):
Inglés
 
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.

Publicación
F200-001-000

Otro(s) idioma(s):
Español
 
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.



Formulario
F207-005-000
 
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.



Formulario
F207-020-111

Otro(s) idioma(s):
Español
 
SIF-5A Cover Sheet: Wage Calculations

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



Formulario
F207-156-000
 
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.



Formulario
F207-164-000

Otro(s) idioma(s):
Español
 
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.



Formulario
F207-165-000

Otro(s) idioma(s):
Español
 
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.

Publicación
F207-202-000

Otro(s) idioma(s):
Español
 
Su Examen Médico Independiente: Para empleadores de negocios autoasegurados

Panfleto: Contesta las preguntas más comunes sobre cuándo y por qué puede requerirse que un trabajador lesionado asista a un examen médico independiente.  Incluye el formulario, "Examen Médico Independiente (IME) Solicitud para el reembolso de gastos de viaje y salario." Esta publicación es para uso solamente de las empresas autoaseguradas y sus trabajadores.



Publicación
F207-202-999

Otro(s) idioma(s):
Inglés
 
Verificación de registro en la escuela

Usada por un estudiante y un oficial de escuela cada trimestre para verificar el registro en la escuela.



Formulario
F242-055-999

Otro(s) idioma(s):
Inglés
 
Address Change Request for Pensioners

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.



Formulario
F242-107-000

Otro(s) idioma(s):
Español
 
Solicitud para cambio de dirección para pensionados

Utilizado por el pensionado para notificarle a L&I de una nueva dirección postal.  L&I debe recibir este formulario para el primer día del mes para que el pago mensual pueda recibirse a tiempo.



Formulario
F242-107-999

Otro(s) idioma(s):
Inglés
 
Employment History Form

Used to provide your employment history for the past three years, including self-employment and volunteer work.

Please start with your most recent job and work backwards. Please list any gaps or interruptions in your work history.  If you were unemployed at any time, please explain why.  Did you apply for (or receive) unemployment benefits during the time period? If yes, what dates did you receive unemployment benefits?  Did you seek employment during the time period?  If no, why didn’t you seek employment?



Formulario
F242-109-000

Otro(s) idioma(s):
Español
 
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.

Formulario
F242-382-000

Otro(s) idioma(s):
Español
 
Carta de intención de registro en una escuela

Utilizado por un estudiante de tiempo completo que tiene derecho a recibir beneficios de pensión.  El estudiante debe tener por lo menos 18 años de edad y no ser mayor de 23 años de edad.  Este formulario es para demostrar la intención del estudiante de registrarse en una escuela acreditada durante el próximo trimestre/semestre.



Formulario
F242-382-999

Otro(s) idioma(s):
Inglés
 
Insurer Activity Prescription Form

Used by health-care providers to communicate an injured worker's status, physical capacities, inability to work (time-loss) and treatment plans. To print an APF, click on the title of the form in the box above.



Formulario
F242-385-000

Otro(s) idioma(s):
Inglés/Español
 
Insurer Activity Prescription Form / Formulario de restricciones laborales del asegurador (English/español)

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

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



Formulario
F242-385-909

Otro(s) idioma(s):
Inglés
 
Independent Medical Exam Doctor's Estimate of Physical Capacities

IME Doctor’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.



Formulario
F242-387-000
 
Application for Pension Benefits by Spouse or Children

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



Formulario
F242-391-000

Otro(s) idioma(s):
Español
 
Independent Medical Exam Comments
Used by the injured worker to provide comments to L&I about their recent medical exam by an IME.

Formulario
F245-053-000

Otro(s) idioma(s):
Español
 
Comentarios Sobre el Exámen Médico Independente

Usado por el trabajador lesionado para proporcionarle comentarios a L&I sobre su examen médico reciente de un Examen Médico Independiente (IME, por su sigla en inglés).



Formulario
F245-053-999

Otro(s) idioma(s):
Inglés
 
Interpretive Services Appointment Record (ISAR)

This form is used by interpreters to verify to L&I (state fund and Crime Victims claims) and self-insured employers for interpretive service at medical or vocational visits.

When ordering, there is a limit of 4 pads, or 100 copies total.



Formulario
F245-056-000
 
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.



Formulario
F245-224-000

Otro(s) idioma(s):
Español
 
Su Examen Médico Independiente

Panfleto/folleto: Respuestas a las preguntas más comunes sobre los exámenes médicos independientes y cuándo y por qué podría requerirse que un trabajador lesionado asistiera a uno.  Incluye el formulario “Examen Médico Independiente (IME) - Solicitud para el reembolso de gastos de viaje y salario.” Este formulario es solamente para el uso de negocios autoasegurados y sus trabajadores.



Formulario
F245-224-999

Otro(s) idioma(s):
Inglés
 
Non-Network Provider Application

Includes the F248-036-000 Statewide Payee Registration and W-9 form. For providers to complete that do not want to become a Labor and Industries network provider, or for a specialty that L&I is not accepting network applications for at this time. If you are applying to be a Labor and Industries network provider, please complete application process at www.ProviderNetwork.Lni.wa.gov



Formulario
F248-011-000
 
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 independent medical exams in Washington's workers' compensation system. Beginning July 1, 2012, free Category I CME credits are available for completing the self-assessment associated with this handbook. Go to www.Imes.Lni.wa.gov and click on Medical Examiners Handbook for information on the exam. 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. Find a medical examiner.



Publicación
F252-001-000
 
Safety Standards for WAC 296-832, Late Night Retail

Crime protection requirements for a retail establishment operating between 11pm and 6am. (Does not include restaurants, hotels, taverns, or any lodging facilities)



Manual
F414-112-000
 
A Safe and Healthy Workplace Begins with You
Pamphlet: Provides an overview of employers' responsibilities for workplace safety and health in Washington State. Covers free L&I services, including workplace consultations, online training and prevention resources and required posters. Intended for new businesses or businesses hiring employees for the first time.

Publicación
F417-210-000
 
Heat-related Illness Education Card/ Tarjeta de educación sobre enfermedades relacionadas con el calor (English/español)

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.

Tarjeta: Identifica los efectos del agotamiento por el calor y la insolación en el cuerpo y lo que puede hacer si observa estos síntomas. Revisa los pasos para la prevención.  El archivo en PDF está configurado para que se impriman dos copias al mismo tiempo.



Publicación
F417-218-909
 
Rental Boiler Operating Permit - Good at this Location Only

To request a permit to use a rental boiler at one location only.

Allow 24 hours for a response. Accuracy and completeness speeds up the processing time.



Formulario
F620-042-000
 
Construction Elevator Installation Application and Inspection 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.

Allow two weeks for a response. Accuracy and completeness speeds up the processing time.



Formulario
F621-001-000
 
Installation Application for Elevators

Used for installation application for elevators (new, renewals, and alterations).

Allow 30 business days for a response. Accuracy and completeness speeds up the processing time.
 
Residential Incline Chair Lifts: Allow one week for a response.



Formulario
F621-005-000
 
Elevator Installation Variance Application

Property owner or elevator company can apply for a variance to install an elevator. 4 pages.

Allow 4-6 weeks for a response.  Accuracy and completeness speeds up the processing time.



Formulario
F621-048-000
 
Extension Request

This form is to request a time extension from an unforeseen circumstances for overdue corrections for conveyances.



Formulario
F621-053-000
 
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.



Formulario
F622-013-000
 
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.

Allow 1-2 days for a response to alteration applications for Manufactured/Mobile Homes.

All other alteration applications, allow 2-3 weeks for a response. Accuracy and completeness speeds up the processing time.



Formulario
F622-036-000
 
Roof Affidavit and Structural Inspection Request

The purpose of the manufactured home roof affidavit is to provide timely inspections and communications between the contractor and/or owner and FAS inspectors and field staff.

A structural inspection request questionnaire will not be required when a roof change out occurs if no structural changes are made in the roof sub-surface and roof cavity. Example: Repairing or replacing the roof trusses, rafters, ridge beam and the replacement of not more than (4) 4’x 8’ of roof sheathing.



Formulario
F622-076-000
 
Affidavit of Wages Paid - Public Works Contract and Instructions

This form is a fillable Word document that is used by a contractor, company or agency to show the wages paid to employees on a public works project. The best way to use this document is to bookmark this page as a “Favorite” in your web browser. Then each time when you want to use the document, access the online version of the form. This will ensure you are always utilizing the most recently published form. (We recommend you not download the document and save the form for future use because we may make changes to the form that your downloaded version will not contain.) You must file the Affidavit of Wages Paid form when you have completed your portion of a public works job/project. Addendum A is form number F700-161-000, Addendum C is form number F700-162-000, and the EHB 2805 (RCW 39.04.370) Addendum is form number F700-164-000.



Formulario
F700-007-000
 
Wage Transcription and Computation Sheet

Employer uses this to show time worked and wages earned for an employee.



Formulario
F700-024-000
 
Statement of Intent to Pay Prevailing Wages - Public Works Contract

This form is a fillable Word document that is used by a contractor, company or agency upon accepting work on a public works project. The best way to use this use this document is to bookmark this page as a “Favorite” in your web browser. Then each time when you want to use the document, access the online version of the form. This will ensure you are always utilizing the most recently published form. (We recommend you not download the document and save it for future use because we may make changes to the form that your downloaded version will not contain.) You should file this form immediately after the contract is awarded and before you begin work. Form number F700-160-000 is addendum A and F700-163-000 is addendum C.



Formulario
F700-029-000
 
Your Rights as a Worker in Washington State/ Sus Derechos como Trabajador en el Estado de Washington (English/Spanish)

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.

Please order from L&I or print on 11" x 17" paper.

Get poster printing tips.

Cartel requerido: Revisa los derechos de los trabajadores bajo las leyes de salario y horas de Washington.  Los temas incluyen el salario mínimo, horas extras, comida y períodos de descanso, deducciones y empleo de adolescentes menores de 18 años de edad.  También revisa las disposiciones de ausencia familiar bajo la ley federal y estatal y la ausencia para los cónyuges del personal militar y las víctimas de violencia doméstica.  Aviso:  Los empleadores tanto en la industria de la agricultura y no agricultura en el estado de Washington deben colocar este cartel donde los trabajadores puedan verlo.

Por favor solicítelo de L&I o imprímalo en papel 11"x 17".

Obtenga consejos para imprimir carteles. 

 

 

 



Cartel
F700-074-909
 
Minimum Wage Law - Truck Drivers

Record keeping provisions and overtime for truck & bus drivers.



Publicación
F700-095-000
 
What You Need to Know if You Don't Get Paid: A Worker's Guide to the Washington State Wage Payment Act / Lo que necesita saber si no recibe su pago: Una guía para el trabajador de la ley del pago de salario del estado de Washington (English/Spanish)

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

Hoja de información:  Hace un resumen de los derechos y responsabilidades de los trabajadores referentes al salario mínimo, pago, horas trabajadas y horas extras y explica cómo presentar una queja de salario, incluye respuestas a varias preguntas frecuentes.



Publicación
F700-153-909
 
Affidavit of Wages Paid EHB 2805 Addendum
F700-164-000 is an addendum to your Affidavit of Wages Paid Form. RCW 39.04.370 requires you to complete form F700-164-000 if the prime contract is at a cost of over one million dollars ($1,000,000). If you fail to properly provide the requested information more than one time between September 1, 2010 and December 31, 2013, pursuant to RCW 39.04.350(1)(f) you will not be considered a responsible bidder qualified to be awarded a public works project. Use as many of these forms as you need in order to provide the requested information for all relevant project items. This is an addendum to form F700-007-000.

Formulario
F700-164-000
 
Solicitud para reabrir un reclamo debido al empeoramiento de la condición

Los beneficios están limitados a $50,000 por reclamo. Si su reclamo ha llegado o excedido  este límite, su solicitud de reapertura será negada y no podremos pagar beneficios futuros.  Usado por las víctimas de crimen y proveedores médicos o de salud mental para solicitar la reapertura de un reclamo.



Formulario
F800-031-999

Otro(s) idioma(s):
Inglés
 
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.



Manual
F800-105-000
 
Victim Verification Form

For use by crime victims requesting wage replacement compensation



Formulario
F800-110-000

Otro(s) idioma(s):
Español
 
Formulario de verificación de empleo

Para ser utilizado por las víctimas de crimen que están solicitando compensación de reemplazo de salario.



Formulario
F800-110-999

Otro(s) idioma(s):
Inglés
 
CVCP Opioid Progress Report Chronic, Non-Cancer Pain and Treatment Agreement.

Crime Victims Compensation Opioid Progress Report Chronic, Non-Cancer Pain and Treatment Agreement.



Formulario
F800-116-000
 
Walk, Don't Run
Timeless reminder to walk, don't run, showing a banana peel. Get poster printing tips.

Cartel
FSP1-051-000
 
A Guide to Workers' Compensation 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.



Publicación
F207-085-000

Otro(s) idioma(s):
Español
 
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.

 



Formulario
F242-052-000

Otro(s) idioma(s):
Español
 
Formulario de verificación de empleo

El trabajador lesionado debe completarlo si no puede trabajar debido a una lesión en el lugar de trabajo y su empleador no le está pagando su salario completo.  



Formulario
F242-052-999

Otro(s) idioma(s):
Inglés
 
Independent Medical Exam Template
Template used by a doctor during an independent medical exam.

Formulario
F245-058-000
 
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.

Publicación
F248-040-000
 
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.



Formulario
F700-065-000
 
Request for Survivor Counseling Benefits / Solicitud para Beneficios de Apoyo para los Sobrevivientes (English/Spanish)  

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

Utilizado por miembros de la familia inmediatos de víctimas de homicidio para solicitar asesoría de salud mental.



Formulario
F800-057-909
 
Notificación de Decisión de Cierre para Reclamos Únicamente Médicos para Empleadores Autoasegurados

Usada solamente por los empleadores autoasegurados o sus representantes, esta es una notificación legal para un trabajador lesionado indicando que su reclamo está cerrado con beneficios médicos solamente.  Esta orden se usa solamente cuando no se ha pagado compensación de tiempo perdido ni tampoco indemnización por discapacidad parcial permanente.



Formulario
F207-020-999

Otro(s) idioma(s):
Inglés
 
Notificación de Decisión de Cierre para reclamos de Tiempo Perdido para Empleadores Autoasegurados

Usada solamente por los empleadores autoasegurados o sus representantes, esta es una notificación legal para un trabajador lesionado indicando que su reclamo está cerrado.  Esta orden se usa solamente cuando se ha pagado compensación de tiempo perdido pero no se está pagando una indemnización por discapacidad parcial permanente.



Formulario
F207-070-999

Otro(s) idioma(s):
Inglés
 
Notificación de Decisión de Cierre con Discapacidad Parcial Permanente para Empleadores Autoasegurados - PPD-TL

Usada solamente por los empleadores autoasegurados o sus representantes, esta es una notificación legal para un trabajador lesionado indicando que su reclamo está cerrado.  Esta orden se usa solamente cuando se ha pagado compensación de tiempo perdido y también se está pagando una indemnización por discapacidad parcial permanente.



Formulario
F207-164-999

Otro(s) idioma(s):
Inglés
 
Address Change Request for Injured Workers
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.

Formulario
F242-388-000

Otro(s) idioma(s):
Español
 
Solicitud para cambio de dirección para trabajadores lesionados

Para ser completada y firmada por un trabajador lesionado del fondo estatal para notificarle a L&I de un cambio de dirección.  Todos lo cambios de dirección deben someterse por escrito y estar firmados por el trabajador lesionado.



Formulario
F242-388-999

Otro(s) idioma(s):
Inglés
 
Independent Medical Examination Fax Cover Sheet
Independent Medical Examination Fax Cover Sheet

Formulario
F245-383-000
 
Notice of Independent Medical Exam No-Show or Late Cancellation
Notice of Independent Medical Exam No-Show or Late Cancellation

Formulario
F245-382-000
 
Declaración firmada para compensación de tiempo perdido

Para ser completada por los trabajadores lesionados que reclaman que tenian derecho a recibir el pago de beneficios de tiempo perdido no pagados anteriormente por un periodo que excede seis meses o $25,000.  Los trabajadores lesionados que soliciten beneficios por el tiempo perdido de trabajo actual debido a una lesión relacionada con el trabajo deben usar el Formulario de verificación de empleo, F242-052-999.



Formulario
F242-395-999

Otro(s) idioma(s):
Inglés
 
Application for Copies of Citation and Notice

Used by an employee to apply for copies of citation and notices issued to their employer.



Formulario
F418-023-000
 
Safety Standards for Administrative Rules WAC 296-900

Administrative Rules and the DOSH Administrative Manual affords employers the right to administrative and judicial review of alleged violations, initial penalties and abatement periods.



Manual
F414-136-000
 





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