| Título |
Tipo |
Número |
2004 Year in Review
Pamphlet/booklet: Provides a financial summary of Washington State's workers' compensation system, July 1, 2003 through June 30, 2004. |
Publication
|
F200-005-000 |
2008 Annual Report for the Washington State Fund: Washington's State-run Workers' Compensation Program
Book: Introduces Washington State's Workers' Compensation Program, including rate-setting and investment policies, financial statement overview, and services available to help employers control workers' comp costs. |
Publication
|
F101-086-000 |
Annual Report of Self-Insured Business, 2008 (SIF-7)
Used by self-insured business for their 2008 Annual Report to L&I. This report must be received by L&I by March 1, 2009. Form is dated 1-09, instructions dated 12-08 are attached to the form. |
Form
|
F207-007-000 |
Application for Elective Coverage - Sole Proprietor, Partners, For-Profit Corporate Officers, or Member/Managers of Limited Liability Company (LLC)
Used by employers to apply for workers' compensation coverage for non-mandatory employment. Shows a list of categories of employment that are not considered mandatory to have workers' compensation. |
Form
|
F213-042-000 |
Authorization for L&I to Accept and Process Quarterly Report from Accountant
Used by employers to give authorization to their accountants to submit quarterly reports in their behalf. |
Form
|
F212-235-000 |
Authorization to Release Claim Information
Available in: Spanish
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. |
Form
|
F101-010-000 |
Cancellation of Elective Coverage - Sole Proprietors/Partner, Member of Limited Liability Company (LLC), Member of Limited Liability Partnership (LLP) or For-Profit Corporate Officers
Used by an employer to cancel workers' compensation coverage for Sole Proprietors/Partner, Member of Limited Liability Company (LLC), Member of Limited Liability Partnership (LLP) or For-Profit Corporate Officers. |
Form
|
F213-004-000 |
Cancellation of Elective Coverage for Excluded Employments
Used by employers to get the categories of employment that are not considered mandatory to have workers' compensation. If they had elected to have coverage this form is used to cancel previously elected coverage of workers' compensation. |
Form
|
F213-005-000 |
Construction Contractor's Application for Worker's Compensation Account with No Worker Hours
Used by employers with no employees or worker hours to report but need an open account for contract bidding process. |
Form
|
F625-077-000 |
Contract: Report By Contractor - Forest, Range & Timber Industry
This report by the contractor needs to be completed and sent before any contractural agreement with a forest, range and/or timber industry landowner can start any work covered by this agreement.
|
Form
|
F213-011-000 |
Contract: Report By Landowner - Forest, Range & Timber Industry
The landowner needs to complete and submit this form before any contractural agreement with a forest, range and/or timber industry contractor can start any work that is covered by this agreement. |
Form
|
F213-010-000 |
Directory of Web Resources for Washington Businesses
Pamphlet: Briefly describes Web pages that contain information of interest to Washington State businesses. Workers' compensation topics include "Quarterly reports--How do I file?" and "Claim-free Discount--Who gets it?" You also will find links to workplace safety rules, sample accident prevention programs, and information about safety grants, plus other information from L&I. Links to other state agency Web sites are included as well. |
Publication
|
F101-084-000 |
Drywall Contractors
Quick reference guide: Used by drywall contractors to get answers to questions about being a drywall contractor and how it relates to L&I. |
Form
|
F214-024-000 |
Employers' Guide to Industrial Insurance
Book: Explains the basic requirements of Washington's industrial insurance law. Suggests ways to protect workers' safety and health and minimize industrial insurance costs. Includes sample forms and L&I telephone numbers. |
Publication
|
F101-002-000 |
Independent Contractors
Quick reference card: Provides information to help determine whether a "subcontractor" working for you meets the legal requirements to be an independent contractor, or whether he/she is actually a covered worker for workers' compensation (industrial insurance) purposes. |
Publication
|
F214-012-000 |
Instructions for completing the Worker's Compensation Employer's Quarterly Report
Instructions for completing the Worker's Compensation Employer's Quarterly Report. A sample of the form F212-055-000 is also available on the internet. |
Form
|
F212-239-000 |
Mechanized Logging Supplemental Quarterly Report
Used by an employer to be submitted with the Employer's Quarterly Report for Industrial Insurance as a supplemental reporting form. |
Form
|
F212-223-000 |
Medical Forms Request
Used to order L&I medical forms. |
Form
|
F208-063-000 |
Notificación de Decisión de Cierre con Discapacidad Parcial Permanente para Empleadores Autoasegurados - PPD-NTL
Available in: English
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. |
Form
|
F207-165-999 |
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. |
Form
|
F248-343-000 |
Quarterly Report for Self-Insured Business
Form used to submit Quarterly Report. If you need a copy of this form to complete your quarterly report, please contact Certification Services at (360) 902-6867. |
Form
|
F207-006-000 |
Quarterly Statement of Supplemental Benefits Instructions
Instructions for filling out the quarterly statement of supplemental benefits. |
Form
|
F207-011-111 |
Quarterly Statement of Supplemental Benefits Paid for Self-Insured Employers
Used by self-insured employers to report their quarterly statement of supplemental benefits. |
Form
|
F207-011-000 |
Record Keeping
Quick reference card: Identifies the type of records employers, including construction contractors, need to keep to allow L&I to compute premiums. |
Publication
|
F214-011-000 |
Reforestation Contract Supplemental Report - Forest, Range and Timber Industry
Used by an employer to report worker hours for each individual contract with a timber landowner. This is a supplemental document to the Contract: Report by Contractor - Forest, Range & Timber Industry (F213-011-000). |
Form
|
F213-013-000 |
Reforestation Industry Continuation Sheet (Over $10,000)
Used by contractors to report contracts over $10,000. Reforestation industry contractors must report worker hours for each individual contract with a timber landowner. This form should accompany the quarterly report. |
Form
|
F213-015-000 |
Self-Insured Employer Certificate of Excess Insurance
Used to provide excess insurance for a self-insurance program. |
Form
|
F207-095-000 |
Social Security Offset Calculations Only Quarterly Statement of Supplemental Benefits Paid for Self-Insured Employers
Used by self-insured employers to request reimbursement from L&I for cost-of-living-adjustments paid to injured workers. |
Form
|
F207-011-222 |
Standard Exception Classification
Quick reference card: Provides basic information about standard exception classifications, which can be separately rated from the basic business classification for determining industrial insurance (workers' compensation) premiums. |
Publication
|
F214-016-000 |
Statement for Home Nursing Services
Used to bill L&I for reimbursement of home nursing services. |
Form
|
F248-160-000 |
Worker's Compensaiton Employer's Quarterly Report for Industrial Insurance - SAMPLE ONLY
You must fill out this form quarterly even if you had no workers. These forms are mailed out quarterly to all employers. For instructions on how to complete the Quarterly Report, please refer to F212-239-000 which is available on the internet. |
Form
|
F212-055-000 |
Workers' Compensation File Information Contract
This is an agreement between an individual and/or firm and L&I which authorizes access to L&I's computer database/application. (5 pages) |
Form
|
F212-197-000 |
Your Workers' Compensation Rate Notice - SAMPLE ONLY
Form used to compute Your Workers' Compensation premiums. Page 2 has rate notice definitions. Sample only. |
Form
|
F225-004-000 |