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

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

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.

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.

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.

This manual contains basic safety and health rules that affect all employers and should cover almost all commercial diving operations. This manual also covers search and rescue and other public safety diving operations.

Booklet: Explains Stay at Work, a financial incentive program that encourages Washington employers to find light-duty or transitional jobs for workers recovering from on-the-job injuries. Provides information on reimbursements, what is covered and how to apply. Detailed Q&A section included.

Used by employers with no employees or worker hours to report but need an open account for contract bidding process.

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.

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.

Covers exemptions to Washington state minimum wage law.

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.

This form is a coversheet used by Self-Insurance for overpayment reimbursement fund requests.

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.

Used by medical providers when reporting initial treatment for an industrial injury or occupational disease for a self-insured claim. Medical providers treating self-insured workers, self-insured businesses, or their third party claims administrators may order copies of this form. Click the "order it" button to request paper copies. If you download the MS Word form, also download the PDF file with instructions on use of the MS Word form. The first file is an Office 2003 MSWord document with a .doc extension. The second file is an Office 2007/2010 version, with a .docx extension.

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

Used by employers to present L&I with a list of decisions they are protesting by adjustment period. The form requests all necessary elements needed for L&I to process a request for reconsideration.

The Core rules contains basic safety and health rules that affect all employers and should cover almost everything small, nonmanufacturing employers need for a safe and healthful workplace.

Provided to workers by the self-insured businesses or their third party claims administrators to report an industrial injury or occupational disease. This form is not on the internet. If you are an injured worker, ask your employer for a copy of this form. Self-insured businesses or their third party claims administrators may order copies of this form. Cllick the "order It" button below to order paper copies or request the form in MSWord.

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

Bill form for prescription charges. May be used by a pharmacy to submit drug charges, or by a worker to request reimbursement for prescriptions paid out of pocket. See the General Provider Billing Manual (F248-100-000) for information on completing this form.

Stay at Work: A new program to help employers keep injured workers on the job--pays half the wage plus expenses (Programa permanezca en el trabajo - Un nuevo programa para ayudar a los empleadores a mantener a los trabajadores lesionados en el trabajo
Also available in: English

Pamphlet/booklet: Provides an overview Stay at Work, a financial incentive program that encourages Washington employers to find light-duty or transitional jobs for workers recovering from on-the-job injuries. Includes information on eligibility, how to apply, and where to get more information.

Pamphlet/booklet: Provides an overview Stay at Work, a financial incentive program that encourages Washington employers to find light-duty or transitional jobs for workers recovering from on-the-job injuries. Includes information on eligibility, how to apply, and where to get more information.

Used by third party attorneys to calculate distribution of proposed settlements in third party claims.

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

Pamphlet/booklet: Provides information about the programs and services financed with workers' compensation premium dollars, along with statistics such as number of claims, demographics of claims and the most frequent types of injuries FY2012 (year ending June 30, 2012). Includes narrative about workers' compensation reforms.

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.

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.

Used by a self-insured employer to change items on the surety document such as amount of letter of credit issued as collateral.

Covers 03A, 06B, 07A, 07B, 07C, 07D, 07E, and 10 specialty licenses.

To exclude or include coverage for a family farm's children.

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.

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).

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.

Used by the worker to designate a person(s) as an authorized representative for the worker's claim. An authorized representative can access claim information.

Fact Sheet: Explains 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.

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.

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.

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

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

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

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

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

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. This information is part of the publication, Workers’ Compensation Record Keeping and Report Guides.

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.

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.

Quick reference card: Explains the criteria to allow a corporate officer to be exempt from industrial insurance (workers' compensation) coverage. This information is part of the publication, Workers’ Compensation Record Keeping and Report Guides.

An agreement between a worker and employer which states the worker's employment is principally localized in Washington state or another state.

Used by a dependent of a worker whose death was related to an on the job injury or accident. This form must be completed, signed, notarized and returned to L&I within 30 days for non interruption of benefits.

Used by a guardian or other person having custody of the minor or disabled children or dependents of a deceased worker to declare their entitlement to receive the pension benefits for those children/dependents in their care and custody.

Used by a totally permanently disabled worker. This form must be completed, signed, notarized and returned to L&I within 30 days for non interruption of benefits.

Used by the widow/widower whose spouse died of a work related injury or accident. This form must be completed, signed, notarized and returned to L&I within 30 days for non interruption of your benefits.

Used by a dependent of a worker whose death was related to an on the job injury or accident. This form must be completed, signed, notarized and returned to L&I within 30 days for non interruption of benefits.

Used by a guardian or other person having custody of the minor or disabled children or dependents of a deceased worker to declare their entitlement to receive the pension benefits for those children/dependents in their care and custody.

Used by a totally permanently disabled worker. This form must be completed, signed, notarized and returned to L&I within 30 days for non interruption of benefits.

Used by the widow/widower whose spouse died of a work related injury or accident. This form must be completed, signed, notarized and returned to L&I within 30 days for non interruption of your benefits.

Covers penalties for employer wage violations. Once stock runs out in warehouse, this form will be internet only.

Pamphlet/booklet: Explains the benefits of 'return to work' from the employer's perspective, describes RTW options, and provides resource and contact information.

Book: Explains the process for employers to provide their own industrial insurance (workers’ compensation) coverage in Washington State. Also reviews surety requirements for self-insurance, reporting and recordkeeping requirements, claims processing, and compliance and legal issues.

Book: Explains the Washington State's workers' compensation program. Suggests ways to protect workers' safety and health and describes L&I programs to help employers control premium costs.

Quick reference card: Provides a list of employments excluded from workers' compensation coverage, including those eligible for optional coverage. This information is part of the publication, Workers’ Compensation Record Keeping and Report Guides.

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.

Covers Farm Labor Contracting Rules for licensing and revocation, violations and legal procedures, and penalties.

Notarized farm labor contractors bond coverage.

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.

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. This information is part of the publication, Workers’ Compensation Record Keeping and Report Guides.

Independent Medical Examination Fax Cover Sheet

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.

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.

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

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.

Quick reference card: Reviews the requirements for members or managers of limited liability companies to be exempt from workers' compensation (industrial insurance) coverage. This information is part of the publication, Workers’ Compensation Record Keeping and Report Guides.

Used by the employer as a quick reference guide to explain which maritime jobs may or may not be covered by L&I.

Used by an employer to be submitted with the Employer's Quarterly Report for Industrial Insurance as a supplemental reporting form.

Used to order L&I medical forms.

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.

Covers Washington State Minimum Wage Law.

Used by self-insured employers or their representatives only, this is legal notification to an injured worker that their claim is being closed. This order is used only when time loss compensation has not been paid, but a permanent partial disability award is being paid.

Used by self-insured employers or their representatives only, this is legal notification to an injured worker that their claim is being closed. This order is used only when time loss compensation has been paid, and a permanent partial disability award is also being paid.

Used by self-insured employers or their representatives, this is legal notification to an injured worker that their claim is being closed. This order is used only when time loss compensation has been paid, but no permanent partial disability award is being paid.

Used by self-insured employers or their representatives, this is legal notification to an injured worker that their claim is being closed with medical benefits only. This order is used only when neither time loss compensation nor a permanent partial disability award has been paid.

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.

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.

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).

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.

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.

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.

The provider network agreement for participation in the health care provider network for injured workers covered by Washington State Fund and self-insured employers.

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.

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

Quick reference card: Identifies the type of records employers, including construction contractors, need to keep to allow L&I to compute premiums. This information is part of the publication, Workers’ Compensation Record Keeping and Report Guides.

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).

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.

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) 902-5300. If you would like the approved Variance Certificate faxed back to your business, please state so on your 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.

Used to provide excess insurance for a self-insurance program.

Used by self-insured employers or their representatives, this is legal notification to an injured worker that their claim is being closed with medical benefits only. This order is used only when neither time loss compensation nor a permanent partial disability award has been paid.

Used by self-insured employers or their representatives only, this is legal notification to an injured worker that their claim is being closed. This order is used only when time loss compensation has not been paid, but a permanent partial disability award is being paid.

Used by self-insured employers or their representatives only, this is legal notification to an injured worker that their claim is being closed. This order is used only when time loss compensation has been paid, and a permanent partial disability award is also being paid.

Used by only self-insured employers or their representatives, this is legal notification to an injured worker that their claim is being closed. This order is used only when time loss compensation has been paid, but no permanent partial disability award is being paid.

Used to provide collateral for a self-insured program.

Used by a sports team or league and professional athlete (player) to declare that the player's work is principally localized in another state in accordance to the provisions of RCW 51.12.120 and WAC 296-17-32503.

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.

Used by a sports team or league covering their Washington players through an out-of-state workers' compensation insurance carrier to confirm compliance with RCW 51.12.120 and WAC 296-17-32503.

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. This information is part of the publication, Workers’ Compensation Record Keeping and Report Guides.

Bill form for use by pharmacies and home infusion companies to submit compound drug charges. This form is for drug charges only, and is filled out by the pharmacist. See the Pharmacy Billing Instructions (F248-021-000) for information on completing this form.

Used to bill L&I for reimbursement of home nursing services.

Pamphlet/booklet: Explains structured settlement and provides an overview of eligibility and the application and approval processes. The audience for this pamphlet is self-insured employers. Employers covered by the state's workers' compensation program should read Publication F240-004-000.

Pamphlet/booklet: Explains structured settlement and provides an overview of eligibility and the application and approval processes. The audience for this pamphlet is employers covered by the state's workers' compensation program. Self-insured employers should read Publication F240-005-000.

Fact sheet: Covers availability, limitations and cost of Washington State's optional workers' compensation coverage for student volunteers.

Used by L&I to assign industrial insurance classifications for workers of temporary help agencies. The first file is a PDF of the Temporary Services Guide to Workers' Compensation Insurance. The second file is a 2003 Excel file. This file is a cross match of non temporary help classifications and the temporary help risk classification associated with that risk class. The third file is a 2003 Excel file. This is a reverse look up for temporary help risk classification and the non temporary classes associated with a temporary help class. File contains an instructions worksheet for the reverse look up worksheet.

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

Routing slip that accompanies the Vocational Services Closing Cover Sheet (F252-028-000) which is used to close vocational services to an injured worker.

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.

Covers compensation for employees in Washington State working overime.

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

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

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.

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)

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.

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.

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

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

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

Pamphlet/booklet: Provides information about the programs and services financed with workers' compensation premium dollars, along with statistics such as number of claims, demographics of claims and the most frequent types of injuries.

Form used to compute Your Workers' Compensation premiums. Page 2 has rate notice definitions. Sample only.