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Statewide Payee Registration and W-9 Form

Use this form to submit your taxpayer ID number. Note: Register now for direct deposit.



Formulario
F248-036-000
 
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.

Publicaci├│n
F248-040-000
 
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.



Formulario
F248-055-000
 
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.



Formulario
F248-343-000
 
Third Party Recovery Worksheet

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



Formulario
F249-006-111
 
Injured by a third party?  

Brochure: Summarizes the legal rights and options an injured worker has if a third-party action pertains to his/her workers' compensation claim. Includes the Third Party Election Form that must be completed by the worker. Note: The form must be printed, signed and mailed.



Formulario
F249-008-000

Otro(s) idioma(s):
Espa├▒ol
 
Application for Inclusion 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.

Formulario
F249-017-000
 
Individual Retrospective Rating Plan Agreement
Used by employers to set up an agreement between them and L&I authorizing their participation in retrospective rating.

Formulario
F250-003-000
 
Application for Group Retrospective Rating
Used by organizations to set up an agreement with L&I authorizing their participation in retrospective rating.

Formulario
F250-004-000
 
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.

Formulario
F250-016-000
 
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.



Publicaci├│n
F252-001-000
 
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.

Formulario
F252-006-000
 
Hearing Impairment Calculation Worksheet
Used by the attending doctor to determine hearing loss.

Formulario
F252-007-000
 
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.



Formulario
F252-013-000
 
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) CURRENT EXISTING VOCATIONAL PROVIDER FIRMS THAT ARE ALREADY REGISTERED WITH L&I USE THIS FORM AND W-9.



Formulario
F252-017-000
 
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.



Formulario
F252-021-000
 
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.



Formulario
F252-022-000
 
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.



Formulario
F252-027-000
 
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.



Formulario
F252-028-000
 
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.



Formulario
F252-032-000
 
Employer's Job Description

Used by employer of record to prepare a written job description for a light-duty job, transitional, 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.



Formulario
F252-040-000
 
Sample Format for Vocational Testing Report

Used by vocational counselors to test an injuried worker's skills and abilities.



Formulario
F252-051-000
 
Sample Format for Vocational Evaluation Testing Plan

Used by vocational counselors to evaluate the testing plan of the injuried worker.



Formulario
F252-052-000
 
Industrial Insurance Discrimination Complaint
Employees who believe they have been discriminated against by their employer use this form to file a complaint.

Formulario
F262-009-000

Otro(s) idioma(s):
Espa├▒ol
 
Queja por Discriminación

Used by employees who believe they have been discriminated against by their employer may use this form to file a complaint.



Formulario
F262-009-999

Otro(s) idioma(s):
Ingl├ęs
 
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 is the continuation sheet.

Formulario
F262-013-000

Otro(s) idioma(s):
Espa├▒ol
 
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.

Formulario
F262-013-111

Otro(s) idioma(s):
Espa├▒ol
 
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.

Formulario
F262-016-000

Otro(s) idioma(s):
Espa├▒ol
 
Cuestionario Sobre la Pérdida 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.



Formulario
F262-016-999

Otro(s) idioma(s):
Ingl├ęs
 
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.

Formulario
F280-010-000
 
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.

Formulario
F280-011-000
 
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.

Formulario
F280-022-000
 
Request for Preferred Workers Status

Used by vocational providers to apply for preferred worker status on behalf of an industrially injured worker.



Formulario
F280-023-000
 
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.

Publicaci├│n
F413-012-000

Otro(s) idioma(s):
ńŞşňŤŻšÜä
ÝĽťŕÁşýŁś
Espa├▒ol
Việt
 
Your Body, Your Job: Preventing Carpal Tunnel Syndrome and Other Upper Extremity Musculoskeletal Disorders
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.

Publicaci├│n
F413-024-000

Otro(s) idioma(s):
Espa├▒ol
 
Su cuerpo, su empleo: Prevenci├│n del S├şndrome del T├║nel Carpiano y otras lesiones m├║sculo esquel├ęticas...

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.



Publicaci├│n
F413-024-999

Otro(s) idioma(s):
Ingl├ęs
 
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.



Formulario
F413-025-000
 
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.

Cartel
F413-049-000
 
Cholinesterase Blood Testing Choice

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



Formulario
F413-064-000

Otro(s) idioma(s):
Espa├▒ol
Espa├▒ol
 
Elección para Prueba de Sangre de Colinesterasa

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



Formulario
F413-064-999

Otro(s) idioma(s):
Ingl├ęs
Ingl├ęs
 
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.



Formulario
F414-021-000
 
Workplace Safety and Health Rules and Guides

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.



CD
F414-074-034
 
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.



Formulario
F416-011-000

Otro(s) idioma(s):
Espa├▒ol
 
Safety and Health Discriminaiton Complaint - (Spanish) Queja de Discriminación de la División de Seguridad Y Salud Ocupacional

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.



Formulario
F416-011-999

Otro(s) idioma(s):
Ingl├ęs
 
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.



Formulario
F416-016-000
 
Application for Charter Boat Operators License

Use this form to apply for an operators license of a charter vessel.



Formulario
F416-034-000
 
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



Formulario
F416-056-000
 
Job Safety and Health Law - Spanish Ley de Seguridad y Salud en el Trabajo (English/Spanish)

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.

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

Get poster printing tips.



Cartel
F416-081-909
 
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. What you type in the top form appears in the bottom one, so you have a copy.



Formulario
F416-087-000
 
A Guide to Workplace Safety and Health in Washington State

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



Publicaci├│n
F416-132-000

Otro(s) idioma(s):
Espa├▒ol
 
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



Formulario
F417-014-000
 
Supervisor's Report of an Accident

Supervisors use this form to document information from an accident or injury.



Formulario
F417-048-000
 
Quick Tips for Lifting/Consejos Breves para Levantar Cargas (English/Spanish)

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



Publicaci├│n
F417-055-909
 
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 standard.



Formulario
F417-102-000
 
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.



Formulario
F417-104-000
 
Fall Protection Work Plan Requirements

This booklet defines the work plan requirements you must meet for fall protection.



Formulario
F417-107-000
 
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.

Publicaci├│n
F417-129-000
 
Office Ergonomics: Practical solutions for a safer workplace
Book: Provides information and tools to analyze office jobs, find problems and develop ergonomic solutions.

Publicaci├│n
F417-133-000
 
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.

Publicaci├│n
F417-140-000
 
Safety and Health Discrimination in the Workplace (English/Spanish)/ Discriminación de seguridad y salud en el lugar de trabajo

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.



Cartel
F417-188-909
 
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.



Manual
F417-196-000
 
Reservation Form Safety and Health Video Library

Use this form to make reservations of safety and health videos. There is both a fillable MS Word form that you can email in, and a fillable PDF that you can fill and print.



Formulario
F417-206-000
 
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.

Publicaci├│n
F417-207-000
 
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.

Publicaci├│n
F417-208-000
 
Keep Your Employees Safe and Working

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.



Publicaci├│n
F417-209-000

Otro(s) idioma(s):
Espa├▒ol
 
Keep Your Employees Safe and Working - Spanish (Mantenga a sus empleados seguros y trabajando)

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.



Publicaci├│n
F417-209-999

Otro(s) idioma(s):
Ingl├ęs
 
Jorge's New Job: Cholinesterase Testing in Washington State - Spanish Un Nuevo Trabajo para Jorge(English/Spanish)

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



Publicaci├│n
F417-213-909
 
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.

Publicaci├│n
F417-214-000
 
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
 
Alleged Safety Or Health Hazards (DOSH Complaint Form)

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



Formulario
F418-052-000

Otro(s) idioma(s):
Espa├▒ol
 
Alleged Safety Or Health Hazards (DOSH Complaint Form) Spanish - Presuntos Riesgos de Salud y Seguridad (Formulario de Queja de DOSH)

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



Formulario
F418-052-999

Otro(s) idioma(s):
Ingl├ęs
 
Application for Amusement Ride or Air Supported Structure Operating Permit

To apply for a decal for an amusement ride or air supported structure.



Formulario
F500-010-000
 
Application for Electrical Contractors License

Application used to get an electrical contractors license



Formulario
F500-018-000
 
Electrical/Telecommunications Contractor's Bond to the State of WA
Used to show proof of a bond in the State of Washington.

Formulario
F500-019-000
 
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.

Formulario
F500-020-000
 
Request for Duplicate or Replacement License or Certificate

To request a duplicate or replacement of your Washington state electrical license or certificate.



Formulario
F500-032-000
 
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.



Formulario
F500-043-000
 
Request for Change of Address

Used by electrical licensee to notify L&I of an address change.



Formulario
F500-044-000
 
Administrator / Electrician / Master Electrician Certificate Renewal

To renew your electrical certificate. Fee varies depending on renewal type.



Formulario
F500-045-000
 
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

Formulario
F500-054-000
 
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.



Formulario
F500-063-000
 
Application for Amusement Ride Inspector Certification

Application to be certified as an amusement ride inspector.



Formulario
F500-065-000
 
Affidavit for Amusement Rides
Affidavit of experience to apply for cetification as a Amusement Ride Inspector.

Formulario
F500-066-000
 
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.



Formulario
F500-068-000
 
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
 
Investigation Report
To notify L&I on any electrical work that you think is illegal.

Formulario
F500-076-000
 
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.



Formulario
F500-077-000
 
Account Deposit for Contractor's or Miscellaneous Account Holder's

Used to deposit money into your L&I account (Electrical).



Formulario
F500-080-000
 
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.

Formulario
F500-087-000
 
Application for Master Electrician Certification Examination

Use this form to apply for the master electrician exam.



Formulario
F500-088-000
 
Electrical Continuing Education Instructor Application

An application to receive approval from L&I to instruct electrical continuing education courses.



Formulario
F500-090-000
 
Contractor Electrical Work Permit Application

This application is used to apply for a valid electrical permit from L&I. 4 pages.



Formulario
F500-093-000
 
Property Owner Electrical Work Permit Application

This application is used to apply for a valid electrical permit. 5 pages.



Formulario
F500-094-000
 
Application for Telecommunications Contractor's License

Application used to get an telecommunications contractors license.



Formulario
F503-008-000
 
Change Assignment of Administrator/Master Certificate

To assign or unassign your status as an administrator or master.



Formulario
F503-009-000
 
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.

Formulario
F620-012-000
 
Shop and Field Inspection Report
Used by L&I inspectors when they inspect boilers.

Formulario
F620-027-000
 
Boiler / Pressure Vessel Water Heater Installation or Reinstallation Permit
This form is filled out by the installer, contractor and/or owner who wants to install or reinstall a boiler.

Formulario
F620-032-000
 
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. Emailed 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.

Formulario
F620-040-000
 
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.

Formulario
F620-041-000
 
Rental Boiler Operating Permit - Good at this Location Only
To request a permit to use a rental boiler at one location only.

Formulario
F620-042-000
 
Historical Boilers Inspection Guideline
Inspection sheet for boiler inspectors. 4 pages.

Formulario
F620-043-000
 
Incident Report Boiler or Pressure Vessel
Used for the reporting of incident with boilers or a pressure vessels.

Formulario
F620-044-000
 
Elevator Installation Variance Application

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



Formulario
F621-048-000
 
Elevator Information Update

This form is required by L&I before they can process any changes to the ownership, physical or mailing address.



Formulario
F621-050-000
 
Elevator Five-Year Safety Test Report

This report is used by L&I for its five-year safety inspection of an elevator.



Formulario
F621-051-000
 
Hydraulic Overpressure Test

To be submitted when a valve is changed or a seal is broken.



Formulario
F621-052-000
 
Extension Request

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



Formulario
F621-053-000
 
Test of Escalator Safety Devices

A licensed elevator mechanic shall perform this test once a year and mail a copy to L&I.



Formulario
F621-055-000
 
Conveyance Installation Approval by Building Official

Used by the installer to notify L&I that a conveyance is proposed for installation in a buildiing.



Formulario
F621-056-000
 
New Elevator Installation Checklist

Checklist for the elevator company/contractor to complete before the call L&I for an elevator inspection. Includes DEc 2010 letter on ASME checklists.



Formulario
F621-057-000
 
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.



Formulario
F621-063-000
 
Request for Duplicate Elevator Certificate

Used to request a duplicate elevator license or a duplicate operating permit for a conveyance.



Formulario
F621-065-000
 
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.



Formulario
F621-067-000
 
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.



Formulario
F621-068-000
 
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.



Formulario
F621-069-000
 
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.

Publicaci├│n
F621-070-000
 
Elevator Continuing Education Course Application

This is used to apply for approval of elevator related continuing education courses.



Formulario
F621-077-000
 
Elevator Continuing Education Instructor Application

Application to become an instructor for elevator related courses.



Formulario
F621-078-000
 
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.



Formulario
F622-006-000
 
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.



Formulario
F622-011-000

Otro(s) idioma(s):
Espa├▒ol
 
Alteration Fire Safety Pre-Inspection Checklist -Spanish Lista de Comprobación para la Preinspección de Seguridad contra Incendios

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



Formulario
F622-011-999

Otro(s) idioma(s):
Ingl├ęs
 
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
 
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.



Formulario
F622-014-000
 
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.



Formulario
F622-015-000
 
Application for State Plan Insignia for Recreational Vehicles and Recreational Park Trailers

To apply for an insignia for a recreational vehicle.



Formulario
F622-021-000
 
Insignia Continuation Sheet Recreational Vehicles and Park Trailers

Continuation sheet to apply for an insignia.



Formulario
F622-021-111
 
Plan Approval Request - Conversion Vendor / Medical Units

Used in requesting a plan approval for Conversion Vendor or Medical Unit factory-assembled structures.



Formulario
F622-035-000
 
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.



Formulario
F622-038-000
 
Alteration Re-Roofing for Low Slope Roofing

Checklist used by the contractor when altering a low slope roof.



Formulario
F622-039-000
 
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.



Formulario
F622-040-000
 
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.



Formulario
F622-043-000
 
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.



Formulario
F622-044-000
 
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.



Formulario
F622-045-000
 
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.



Formulario
F622-046-000
 
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.



Formulario
F622-048-000
 
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.

Publicaci├│n
F622-049-000

Otro(s) idioma(s):
Espa├▒ol
 
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.



Formulario
F622-053-000
 
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.



Formulario
F622-054-000
 
Decertification of Manufactured and Mobile Homes

This document shows the steps to decertify a manufactured or mobile home.



Formulario
F622-063-000
 
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.



Formulario
F623-006-000
 
Notification to Local Enforcement Agency

L&I sends this form to notify the local agencies when a factory-built structure is being shipped within a county or city limits.



Formulario
F623-013-000
 
Application for Insignia for Factory Assembled Structures

Manufacturers uses this form to apply for an official insignia for a factory-built structure that has a plan approval number.



Formulario
F623-014-000
 
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.



Formulario
F623-019-000
 
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.



Formulario
F623-021-000
 
Application for Construction Contractor Registration

This is the form you would complete to register as a construction contractor.



Formulario
F625-001-000
 
Facts About Construction Liens
Fact sheet: Explains the basics of the construction lien law to help consumers protect themselves.

Publicaci├│n
F625-017-000
 
Waiver of Lien by Contractor, Subcontractor(s) and Supplier

This is a waiver of lien by a contractor or a subcontractor or supplier.



Formulario
F625-029-000
 
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.



Formulario
F625-030-000
 
Contractor Complaint Form

Used by a home owner to file a complaint against a contractor.



Formulario
F625-033-000
 
Construction Contractors: Get the Facts, Get Registered
Pamphlet/booklet: Explains the steps to register as a construction contractor in Washington State.

Publicaci├│n
F625-040-000

Otro(s) idioma(s):
Espa├▒ol
 
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.



Formulario
F625-051-000
 
Filing Suit Against an Electrical Contractor

Instructions for filing suit against an electrical contractor



Formulario
F625-053-000
 
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.



Formulario
F625-054-000
 
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.



Formulario
F625-055-000
 
Contractor Financial Information

Used by the contractor to request L&I to release assignment of account that they used instead of a surety bond.



Formulario
F625-061-000
 
Affidavit to Release Public Records

This form is to request L&I to release public records in the contractors registration section.



Formulario
F625-066-000
 
What You Should Know About Hiring a Contractor, Remodeler, or Handyman

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.



Publicaci├│n
F625-084-000

Otro(s) idioma(s):
Espa├▒ol
 
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.



Publicaci├│n
F625-088-000
 
Request for Archive Records - Contractor Registration

This form is to request L&I to release archive records in the contractors registration section.



Formulario
F625-094-000
 
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). This publication currently unavailable due to revisions in progress. Check back for updates.



Publicaci├│n
F625-097-000
 
Application for Electrician Examination

Application and instructions for a Washington State electrician's certificate examination.



Formulario
F626-001-000
 
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).



Formulario
F626-048-000
 
Application for Plumber Trainee Certificate

This form is used to apply for a plumber trainee certificate.



Formulario
F627-003-000
 
Affidavit of Experience - Plumbers

This form is required to report plumber trainee's plumbing experience for credit towards journey level or specialty status.



Formulario
F627-004-000
 
Application for Plumber Examination, Reciprocal, Medical Gas Endorsement, or Temporary Permit

This form is used to apply for plumber examination, reciprocal and medical gas endorsement.



Formulario
F627-008-000
 
Request for Duplicate or Replacement Certificate

This form is used to request a duplicate or replacement certificate for a plumber or plumber trainee.



Formulario
F627-014-000
 
Plumber, Medical Gas, or Trainee Renewal

This form is used to renew a plumber certification, plumber trainee or medical gas installer certification.



Formulario
F627-019-000
 
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.

Publicaci├│n
F627-022-000
 
Facts about Medical Gas Piping Installer Endorsement
Fact sheet: Explains training requirements and the endorsement process for medical gas piping installers.

Publicaci├│n
F627-026-000
 
Plumbers Examination Dates and Locations

The 2014 Plumber Examination Dates and Locations. A printed version is also available from the L&I Warehouse.



Formulario
F627-027-000
 
Application for Backflow Trainee Certificate

This form is used to apply for a backflow trainee certificate.



Formulario
F627-033-000
 
Application for Backflow Specialty Exam

This form is used to apply for the backflow specialty examination.



Formulario
F627-035-000
 
Plumber Continuing Education Course Application

This form is used by the course sponsor to submit continuing education courses for plumber certification.



Formulario
F627-037-000
 
Parent / School Authorization for Employment of a Minor and Special Variance

For legal guardians and school officials to approve the hours and work activities for a minor employee to work according to terms listed by the employer. The Special Variance allows additional hours of work for 16- and 17-year-olds and is described on the form. All parties must sign to approve the hours of work for a minor regardless of the number of hours listed. 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.

For hiring youth only during non-school weeks, you may use form F700-168-000 Parent Authorization Summer Work  



Formulario
F700-002-000
 
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
 
Record Keeping Provisions - Employment Standards

This form is for employers to use to keep records on every employee.



Formulario
F700-009-000
 
Application for Farm Labor Contractor License

Used to apply or renew a license.



Formulario
F700-014-000
 
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.



Publicaci├│n
F700-022-000

Otro(s) idioma(s):
Espa├▒ol
 
Wage Transcription and Computation Sheet

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



Formulario
F700-024-000
 
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.



Formulario
F700-146-000

Otro(s) idioma(s):
Espa├▒ol
 
Prevailing Wage Complaint Instructions - Spanish - Instrucciones para el Registro de una Queja Sobre Salario Prevaleciente

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



Formulario
F700-146-999

Otro(s) idioma(s):
Ingl├ęs
 
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
 
Agreement - Farm Labor Contractors and Workers

Employment wages and conditions agreement with Farm Labor Contractors and Workers



Formulario
F700-046-000

Otro(s) idioma(s):
Espa├▒ol
 
Agreement - Farm Labor Contractors and Workers - Spanish - Acuerdo entre Contratistas Agrícolas y Trabajadores

Employment wages and conditions agreement with Farm Labor Contractors and Workers



Formulario
F700-046-999

Otro(s) idioma(s):
Ingl├ęs
 
Farm Labor Contractor Assignment of Account or Time Deposit

Farm Labor Contractor assignment of account or tme deposit for employee



Formulario
F700-060-000
 
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.



Formulario
F700-064-000
 
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
 
Farm Labor Contractors Bond

Notarized farm labor contractors bond coverage.



Formulario
F700-066-000
 
What Are Your Rights When You Work for a Farm Labor Contractor? (English/Spanish) / ┬┐Cúales son sus derechos cuando trabaja para un contratista de trabajadores agrícolas?
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.

Publicaci├│n
F700-067-909
 
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
F700-074-909
 
Variance Application - For exceptions from specific rules governing employment of minors.

Employer uses this application for requesting a variance to employment regulations for minors.



Formulario
F700-076-000
 
Farm Labor Contractor Registration

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



Publicaci├│n
F700-088-000

Otro(s) idioma(s):
Espa├▒ol
 
Variance Application - Employment Standards

Employer application request for a variance from employment standards for non minor employees.



Formulario
F700-089-000
 
Young Workers in Agriculture/Trabajadores j├│venes en la agricultura (English/Spanish)

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.



Publicaci├│n
F700-096-909
 
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.



Formulario
F700-098-000
 
Department of Employment Security Tax Compliance Certification

Form to gain Department of Employment Security Tax Compliance Certification for registered Farm Labor Contractors.



Formulario
F700-099-000
 
Department of Revenue Tax Compliance Certification

Form to gain Department of Revenue Tax Compliance Certification for registered Farm Labor Contractors.



Formulario
F700-100-000
 
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.

Publicaci├│n
F700-105-909
 
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.



Formulario
F700-109-000

Otro(s) idioma(s):
Espa├▒ol
 
Formulario de Queja en Contra de un Contratista de Trabajores Agrícolas (Farm Labor Contractor Complaint)

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



Formulario
F700-109-999

Otro(s) idioma(s):
Ingl├ęs
 
Farm Labor Contractor Checklist

Farm Labor Contractor's Checklist to ensure compliance.



Formulario
F700-112-000

Otro(s) idioma(s):
Espa├▒ol
 
Employing Children 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.



Publicaci├│n
F700-117-000
 
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.



Formulario
F700-118-000
 
Court Form Granting Permission for Employment of Minors

Form from Court Granting Permission for Employment of Minors to the employer.



Formulario
F700-119-000
 
Application for Special Certificate to Employ at A Subminimum Wage Rate

Employer Application for Special Certificate to Employ at A Subminimum Wage Rate.



Formulario
F700-120-000
 
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



Formulario
F700-122-000
 
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):
Espa├▒ol
 
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):
Espa├▒ol
 
Application for Benefits- Crime Victims Spanish - Instrucciones para: Solicitud para Beneficios para Víctimas de Crimen

Instructions in Spanish to complete the English form F800-042-000 Application for Crime Victim benefits. The form is used by victims of a crime in Washington State to receive benefits for time lost from work, loss of financial support, medical or mental health treatment. This 12-10 version is internet only.



Formulario
F800-042-999

Otro(s) idioma(s):
Ingl├ęs
 
Request for Survivor Counseling Benefits (English/Spanish) Solicitud para Beneficios de Apoyo para los Sobrevivientes  

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



Formulario
F800-057-909
 
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 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.



Publicaci├│n
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
 
Safety Comes Thru Job Training
A supervisor having a discussion with his crew. Get poster printing tips.

Cartel
FSP0-901-000
 
Poster - An Unprotected Trench is an Early Grave

Poster: Trench safety information for employers. Features tips to prevent cave-ins, and proper inspection proceedures. Get poster printing tips.



Cartel
FSP0-912-000
 
Caution: Hard Hat Area
Visual reminder of the importance of wearing a hard hat. Get poster printing tips.

Cartel
FSP0-928-000

Otro(s) idioma(s):
Espa├▒ol
 
Precaución: Obligatorio Usar Casco
Picture of hard hats. Get poster printing tips.

Cartel
FSP0-928-999

Otro(s) idioma(s):
Ingl├ęs
 
Siempre Use Protección para los ojos
Picture of a large eye with some content on when to use eye protection. Get poster printing tips.

Cartel
FSP0-940-999

Otro(s) idioma(s):
Ingl├ęs
 
Always Wear Eye Protection

Sticker: 7.25 inches X 4.25 inches.



Calcoman├şa
FSP0-941-000
 
Danger! Minimum Clearance for Counter Balance - Construction

Sticker: 30 inches long.



Calcoman├şa
FSP0-974-000
 
Put this Guard Back - 8.5 x 3.5 inches

Sticker: 8.5 inches X 3.5 inches



Calcoman├şa
FSP0-993-000

Otro(s) idioma(s):
Espa├▒ol
 
Put this Guard Back - 5 1/2 x 2 1/8 inches

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



Calcoman├şa
FSP0-993-001

Otro(s) idioma(s):
Espa├▒ol
 
 Si usted TIENE que remover este resguardo 8.5 x 5.5

Sticker: 8.5 inches X 3.5 inches



Calcoman├şa
FSP0-993-999

Otro(s) idioma(s):
Ingl├ęs
 
Grinding Wheel - Prevent Accidents

Sticker size 4"x3"



Calcoman├şa
FSP1-000-000
 
Report All Injuries Promptly
Large words: Report All Injuries Promptly. Get poster printing tips.

Cartel
FSP1-004-000

Otro(s) idioma(s):
Espa├▒ol
 
Reporte Todas las Lesiones Inmediatamente

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



Cartel
FSP1-004-999

Otro(s) idioma(s):
Ingl├ęs
 
First Aid

Safety Sticker size 5"x6"



Calcoman├şa
FSP1-005-000
 
Danger, Workers Above
Picture of workers on a high rise. Get poster printing tips.

Cartel
FSP1-012-000

Otro(s) idioma(s):
Espa├▒ol
 
Danger, Workers Above-Spanish (Peligro - Trabajadores en el Nivel Superior)

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



Cartel
FSP1-012-999

Otro(s) idioma(s):
Ingl├ęs
 
Danger, Construction Area Authorized Personnel Only
Large words: Danger, Construction Area Authorized Personnel Only. Get poster printing tips.

Cartel
FSP1-013-000

Otro(s) idioma(s):
Espa├▒ol
 
Peligro - Área en Construcción - Solamente Personas Authorizadas

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



Cartel
FSP1-013-999

Otro(s) idioma(s):
Ingl├ęs
 
Danger
Large lettering: DANGER. Get poster printing tips.

Cartel
FSP1-030-000

Otro(s) idioma(s):
Espa├▒ol
 
Cartel - PELIGRO

Large lettering: PELIGRO



Cartel
FSP1-030-999

Otro(s) idioma(s):
Ingl├ęs
 
Know Your Lockout Tagout Safety Procedures
Poster: Visual reminder you can print for posting in appropriate workplaces. Two options available for download and/or printing.

Cartel
FSP1-063-000
 
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):
Espa├▒ol
 
Notificación de Decisión de Cierre para Reclamos Únicamente Médicos 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.



Formulario
F207-020-999

Otro(s) idioma(s):
Ingl├ęs
 
Notificación de Decisión 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.



Formulario
F207-070-999

Otro(s) idioma(s):
Ingl├ęs
 
Notificación de Decisión 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.



Formulario
F207-164-999

Otro(s) idioma(s):
Ingl├ęs
 
Notificación de Decisión 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.



Formulario
F207-165-999

Otro(s) idioma(s):
Ingl├ęs
 
Hearing Services Worker Information

This is a list of the rights and conditions when an injured worker applies for hearing aids.



Formulario
F245-049-000
 
Termination of Agreement (Rescission)
To be filled out by the injured worker who wants to return hearing aids.

Formulario
F245-050-000
 
Complete Stay at Work Guide for Employers, The

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.



Publicaci├│n
F243-005-000
 
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):
Espa├▒ol
 
Stay at Work: A new program to help employers keep injured workers on the job--pays half the wage plus expenses

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.



Publicaci├│n
F243-006-000

Otro(s) idioma(s):
Espa├▒ol
 
Stay at Work: A new program to help employers keep injured workers on the job--pays half the wage plus expenses (Permanezca en el Trabajo: Una Solución Factible -- Un programa para ayudar a los empleadores a mantener a los trabajadores lesionados en el trabajo -- paga la mitad del salario base además de otros gastos).

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.



Publicaci├│n
F243-006-999

Otro(s) idioma(s):
Ingl├ęs
 
Comentarios Sobre el Ex├ímen M├ędico Independente
Used by the injured worker to provide comments to L&I about their recent medical exam by an IME.

Formulario
F245-053-999

Otro(s) idioma(s):
Ingl├ęs
 
Is Retrospective Rating Right for You?
Pamphlet: Provides information about L&I's Retrospective Rating Program. In Retro, employers can earn a partial refund of workers' compensation premiums if they reduce workplace injuries and lower associated claim costs.

Publicaci├│n
F250-006-000
 
Stay at Work Wage Reimbursement Application for Employers

Employer of record can request reimbursement for wages paid to an injured worker during light duty or transitional work. After completing the form, the employer submits it, along with supporting documentation, to the Stay at Work program for review and approval. For expense reimbursements see F243-003-000.



Formulario
F243-001-000
 
Stay at Work Expense Reimbursement Application for Employers Tools, Clothing, Training.

Employer of record can request reimbursement for tools, clothing, or training expenses required to enable an injured worker to return to light duty or transitional work. After completing the form, the employer submits it, along with supporting documentation, to the Stay at Work program for review and approval. For wage reimbursements see F243-001-000.



Formulario
F243-003-000
 
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.



Formulario
F413-068-000
 





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