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Regresando a Trabajar es su Trabajo y su Futuro

Panfleto/folleto:  Explica brevemente los pasos para regresar a trabajar rápidamente y reducir el impacto económico del tiempo perdido.  También proporciona recursos útiles.  Destinado para trabajadores lesionados.

 

 



Publicación
F200-001-999

Otro(s) idioma(s):
Inglés
 
Attending Provider's Return-to-Work Desk Reference
Book: Discusses best practices in occupational medicine that help return an injured worker to his/her job as soon as medically possible. Identifies resources available from L&I and explains how to bill for return-to-work services. Three hours of Category 1 CME credit are offered for completing an online self-assessment. Go to www.CMECredits.Lni.wa.gov.

Publicación
F200-002-000
 
Employer's Return-to-Work Guide

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



Publicación
F200-003-000
 
Application for Self-Insurance Certification

Used by employers to apply for self-insurance certification.



Formulario
F207-001-000
 
Self-Insurance Report of Occupational Injury or Disease (SIF-5)

Used by only self-insured employers or their representatives to report initial time loss payments or to request interlocutory, wage, overpayment or closure orders.



Formulario
F207-005-000
 
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.



Formulario
F207-006-000
 
Quarterly Statement of Supplemental Benefits Paid for Self-Insured Employers

Used by self-insured employers to report their quarterly statement of supplemental benefits.



Formulario
F207-011-000
 
Quarterly Statement of Supplemental Benefits Instructions

Instructions for filling out the quarterly statement of supplemental benefits.



Formulario
F207-011-111
 
Special Escrow Agreement
Used by self-insured employer as a means to provide surety. This is an agreement between the self-insurer and the bank to hold these securities in trust as collateral for its self-insured program.

Formulario
F207-039-000
 
Agreement of Assumption and Guarantee of Workers' Compensation Liabilities - Application of Certification

Used by an employer to apply for self-insurance.



Formulario
F207-040-000
 
Agreement of Assumption and Guarantee of Workers' Compensation Liabilities (Certified Self-Insurer)

Used by certified self-insured companies when they are acquired by another organization. New parent organization guarantees the self-insured workers' compensation liabilities of its new subsidiary.



Formulario
F207-040-001
 
Assignment of Account Agreement
Used by a self-insured employer as an option to provide collateral for a total permanent disability claim.

Formulario
F207-058-000
 
Self-Insurer's Pension Bond

Used by self-insured employers as an option to provide collateral for a permanent total disability claim.



Formulario
F207-065-000
 
Self-Insurer's Bond - Existing Liabilities
Used to provide collateral for a self-insured program.

Formulario
F207-068-000
 
Self-Insured Employers' Time Loss Claim Closure Order and Notice

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



Formulario
F207-070-000

Otro(s) idioma(s):
Español
 
A Guide to Workers' Compensation Benefits For Employees of Self-Insured Businesses

Pamphlet/booklet: Explains to employees of self-insured businesses their rights and responsibilities under industrial insurance law. Describes benefits and how to file a claim.



Publicación
F207-085-000

Otro(s) idioma(s):
Español
 
Self-Insured Employer Certificate of Excess Insurance

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



Formulario
F207-095-000
 
Irrevocable Standby Letter of Credit

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



Formulario
F207-112-000
 
Amendment of Irrevocable Standby Letter of Credit

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



Formulario
F207-112-111
 
Memorandum of Understanding Irrevocable Standby Letter of Credit

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.



Formulario
F207-113-000
 
Pension Bond Rider
Used by a self-insured employer to change items on the surety document such as amount of pension bond issued to secure a total permanent disability claim.

Formulario
F207-120-000
 
Annual Supplemental Surety Information

Used by self-insured employers to assist in fulfilling surety requirements.



Formulario
F207-125-000
 
Memorandum of Understanding

Used by a self-insured employer to signify the employer's obligation and responsibilities in conjunction with providing an annuity as collateral for a total permanent disability claim.



Formulario
F207-129-000
 
Surety Rider
Used by a self-insured employer to amend or change items on the surety document such as the amount of a surety bond used as collateral.

Formulario
F207-134-000
 
Special Escrow Account - Amendment Agreement
Used by a self-insured employer to amend or change items on the surety document such as the amount of the escrow agreement used as collateral.

Formulario
F207-137-000
 
Acknowledgement of Security Interest
Used to acknowledge that funds have been deposited into an account at a bank for the purpose of providing payment for the workers' compensation benefits and assessments in the event of default by the self-insurer.

Formulario
F207-143-000
 
Workers' Compensation Filing Information

Used by only self-insured employers to comply with WAC 296-15-400. The form provides information and instructions to employees of self-insured employers in case of an injury or development of an occupational disease.



Formulario
F207-155-000

Otro(s) idioma(s):
Español
 
Cómo Registrar un Reclamo para la Compensación del Trabajador con Empresas Autoaseguradas

Usado solamente por los empleadores autoasegurados para cumplir con el Código Administrativo de Washington (WAC, por su sigla en inglés) 296-15-400.  El formulario proporciona información e instrucciones para los empleados de empleadores autoasegurados en caso de una lesión o desarrollo de una enfermedad ocupacional.



Formulario
F207-155-999

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

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



Formulario
F207-156-000
 
Self-Insured Employers' Permanent Partial Disability Closure Order and Notice - PPD-TL

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



Formulario
F207-164-000

Otro(s) idioma(s):
Español
 
Self-Insured Employers' Permanent Partial Disability Closure Order and Notice - PPD-NTL

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



Formulario
F207-165-000

Otro(s) idioma(s):
Español
 
Self-Insurance Vocational Services Closing 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.

Formulario
F207-171-000
 
Certificate of Coverage - SAMPLE ONLY

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



Formulario
F211-141-000

Otro(s) idioma(s):
Español
 
Certificado de Cobertura - Ejemplo

Ejemplo que muestra una copia del Certificado de cobertura.  Usted debe solicitar el formulario, no puede descargarlo de la Internet.



Formulario
F211-141-999

Otro(s) idioma(s):
Inglés
 
Maritime Coverage

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



Formulario
F212-034-000
 
Coverage Agreement

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



Formulario
F212-044-000
 
Drywall Industry - Owner/Sub-Contractor Report

Used by drywall companies to file their quarterly report. Must accompany the Supplemental Quarterly Report for the Drywall Industry (F212-051-000).



Formulario
F212-050-000
 
Supplemental Quarterly Report for the Drywall Industry

Used by drywall companies to file their quarterly report. Must accompany the Drywall Industry Owner/Sub-Contractor Report (F212-050-000).



Formulario
F212-051-000
 
Workers' Compensation Employer's Quarterly Report - 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. This file on the internet is a sample only.



Formulario
F212-055-000
 
Sports Teams Coverage Agreement

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.



Formulario
F212-196-000
 
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.



Formulario
F212-223-000
 
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.



Formulario
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.



Formulario
F213-005-000
 
Construction Industry Classification Guide

Book (loose-leaf manual): Helps contractors properly classify for workers' compensation insurance purposes the work being performed by their employees on new wood-frame building construction projects.



Publicación
F213-008-000
 
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.



Formulario
F213-010-000
 
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.



Formulario
F213-011-000
 
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).



Formulario
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.



Formulario
F213-015-000
 
Student Volunteers and Workers' Compensation Coverage

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



Publicación
F213-023-000
 
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.



Formulario
F213-042-000
 
Application for Exclusion/Inclusion - Mandatory Coverage (Family Farm)

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



Formulario
F213-113-000
 
Record Keeping

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



Publicación
F214-011-000
 
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. This information is part of the publication, Workers’ Compensation Record Keeping and Report Guides.



Publicación
F214-012-000
 
Excluded and Exempt Employments

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.



Publicación
F214-013-000
 
Computing Worker Hours

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.



Publicación
F214-014-000
 
Audit Reference Card
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.

Publicación
F214-020-000
 
Limited Liability Companies (LLC)

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.



Publicación
F214-021-000
 
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.



Formulario
F214-024-000
 
Your Workers' Compensation Rate Notice - SAMPLE ONLY

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



Formulario
F225-004-000
 
Request for Manuals from Claims Training

Fillable form to purchase the Workers’ Compensation Adjudicator (WCA), Claims Management (CM), and Policy Manuals (all 3 manuals on 1 CD) the costs will be added up automatically, the total amount enclosed column will be the amount you need to send as payment.



Formulario
F241-021-000
 
Worker Verification Form

Completed by the injured worker if they are unable to work due to a workplace injury AND their employer is not paying their full wages.

 



Formulario
F242-052-000

Otro(s) idioma(s):
Español
 
Formulario de Verificación de Empleo

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



Formulario
F242-052-999

Otro(s) idioma(s):
Inglés
 
Verification of School Enrollment

Used by the student and a school official each quarter to verify school enrollment.



Formulario
F242-055-000

Otro(s) idioma(s):
Español
 
Claim for Pension by Spouse or Children
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.

Formulario
F242-056-000

Otro(s) idioma(s):
Español
 
Reclamo para Beneficios de Pensión Presentado por el Cónyuge, Pareja Doméstica Registrada o los Hijos

Usado por el cónyuge o dependientes de un trabajador fallecido. EL accidente fatal o enfermedad ocupacional del trabajador que ocurrió en el transcurso del empleo.  Esta solicitud es necesaria para determinar si el(los) solicitante(s) tienen derecho a recibir beneficio de sobreviviente.



Formulario
F242-056-999

Otro(s) idioma(s):
Inglés
 
Claim for Pension By Dependents
Used by dependents of a deceased worker to file a claim for benefits.

Formulario
F242-062-000

Otro(s) idioma(s):
Español
 
Reclamo para Beneficios de Pensión Presentado por los Dependientes

Usado por los dependientes de un trabajador fallecido para presentar un reclamo para beneficios.



Formulario
F242-062-999

Otro(s) idioma(s):
Inglés
 
Occupational Disease & Employment History

Injured worker fills this out to document possible occupational disease and to show work history.



Formulario
F242-071-000

Otro(s) idioma(s):
Español
 
Continuación del Historial de Trabajo y de Enfermedad Ocupacional

El trabajador lesionado llena este formulario para documentar una posible enfermedad ocupacional y para mostrar su historia de trabajo.



Formulario
F242-071-911

Otro(s) idioma(s):
Inglés
 
Historial de Trabajo (Enfermedad Ocupacional)

El trabajador lesionado llena este documento para presentar su historia de trabajo.  El formulario de continuación a esta página es F242-071-911.



Formulario
F242-071-999

Otro(s) idioma(s):
Inglés
Español
 
Application to Reopen Claim Due to Worsening Condition

This application is by injured workers and providers to apply to reopen an industrial injury or occupational disease claim due to worsening condition for claims that have been claims 60 days or longer.



Formulario
F242-079-000

Otro(s) idioma(s):
Inglés/Español
Español
 
Workers' Compensation Benefits: A Guide for Injured Workers

Pamphlet/booklet: For workers covered by L&I (the State Fund). Describes benefits if you have a work-related injury or illness and how to file a claim. Explains a worker's rights and responsibilities under Washington State's industrial insurance law. Note: Previously titled, Workers' Guide to Industrial Insurance Benefits.



Publicación
F242-104-000

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

Used by the pensioner to notify L&I of a new mailing address. L&I must receive this form by the first day of the month so your monthly payment is received in a timely manner.



Formulario
F242-107-000

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

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



Formulario
F242-107-999

Otro(s) idioma(s):
Inglés
 
Report of Accident (ROA) Workplace Injury, Accident or Occupational Disease

This form is not available to download. If you are an injured worker, ask your medical provider for a copy of this form or you can complete your portion of the Report of Accident (ROA) online at https://secure.Lni.wa.gov/home.

Please note only medical providers may order this form from the Warehouse.



Formulario
F242-130-000

Otro(s) idioma(s):
Español
 
Declaration of Entitlement for Widow or Widower Benefits Under Industrial Insurance
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.

Formulario
F242-173-111

Otro(s) idioma(s):
Español
 
Declaration of Entitlement for Guardian Benefits under Industrial Insurance
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.

Formulario
F242-173-222

Otro(s) idioma(s):
Español
 
Declaration of Entitlement for Dependent of Deceased Worker Benefits Under Industrial Insurance
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.

Formulario
F242-173-333

Otro(s) idioma(s):
Español
 
Declaration of Entitlement for Totally Disabled Worker Benefits Under Industrial Insurance
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.

Formulario
F242-173-444

Otro(s) idioma(s):
Español
 
Declaración de Derechos para Viuda(o) bajo el Programa de Compensación y Beneficios para Trabajadores

Usado por una viuda/viudo cuyo cónyuge falleció a causa de una lesión o accidente relacionado con el trabajo.  Este formulario debe completarse, firmarse, notariarse y devolverse a L&I dentro de 30 días para que los beneficios no sean interrumpidos.



Formulario
F242-173-911

Otro(s) idioma(s):
Inglés
 
Declaración de Derechos para Padres o Tutor Bajo el Programa de Compensación y Beneficios para Trabajadores

Usado por un tutor u otra persona que tiene custodia del hijo menor o discapacitado o dependientes de un trabajador fallecido para declarar su  derecho a recibir los beneficios de pensión para aquellos niños/dependientes bajo su cuidado y custodia.



Formulario
F242-173-922

Otro(s) idioma(s):
Inglés
 
Declaración de Derechos para Dependiente del Trabajador Fallecido Bajo el Programa de Compensación y Beneficios para Trabajadores

Usado por un dependiente de un trabajador cuya muerte estaba relacionada con una lesión o accidente en el trabajo.  Este formulario debe completarse, firmarse, notariarse y devolverse a L&I dentro de 30 días para que los beneficios no sean interrumpidos.



Formulario
F242-173-933

Otro(s) idioma(s):
Inglés
 
Declaración de Derechos para los Beneficios de un Trabajador Totalmente Discapacitado Bajo las Leyes del Seguro Industrial

Usado por un trabajador permanentemente y totalmente discapacitado.  Este formulario debe completarse, firmarse, notariarse y devolverse a L&I dentro de 30 días para que los beneficios no sean interrumpidos.



Formulario
F242-173-944

Otro(s) idioma(s):
Inglés
 
Authorization for Deposit of Payments

Used by pensioner to authorize L&I to deposit the pension payment to any designated financial institution.



Formulario
F242-174-000

Otro(s) idioma(s):
Inglés/Español
 
Notice to Employees -- If a Job Injury Occurs/Aviso a los empleados--Si Ocurre una Lesión en el Trabajo (English/Spanish)

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.

Cartel requerido:  Describe los pasos que un trabajador debe tomar si le ocurre una lesión o enfermedad relacionada con el trabajo.  También describe brevemente los beneficios disponibles a través del sistema de compensación para los trabajadores de Washington.  Aviso:  Los empleadores que reciben cobertura de seguro industrial de L&I deben colocar este cartel donde los trabajadores puedan verlo.  Las versiones en línea en ingés y español se imprimirán por separado.



Cartel
F242-191-909
 
Statement for Retraining and Job Modification Services

Bill form for providers that bill the department for claim-related retraining and job modification services. See the General Provider Billing Manual (248-100-000) for information on completing this form.



Formulario
F245-030-000

Otro(s) idioma(s):
Español
 
Transfer of Care Card

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



Formulario
F245-037-000

Otro(s) idioma(s):
Español
 
Tarjeta para Transferencia de Caso

Usada por los trabajadores lesionados para notificar al gerente de reclamo y solicitar autorización para transferir el cuidado a un doctor diferente.



Formulario
F245-037-999

Otro(s) idioma(s):
Inglés
 
Statement for Miscellaneous Services

This bill form is used by providers and injured workers to bill the department for services such as dental care; glasses; medical equipment; nursing home services; interpreter services; services workers pay for out of pocket; and other services. Information on how to bill the department can be found in the General Provider Billing Manual [F248-100-000].

 



Formulario
F245-072-000

Otro(s) idioma(s):
Español
 
Travel Reimbursement Request

Bill form for use by workers to request reimbursement for authorized travel expenses.



Formulario
F245-145-000

Otro(s) idioma(s):
Español
 
Solicitud para el Reembolso de Gastos de Viaje

Los trabajadores lesionados usan este formulario para solicitar reembolso de los gastos de viaje usados para recibir tratamiento, capacitación y/o servicios vocacionales.



Formulario
F245-145-999

Otro(s) idioma(s):
Inglés
 
Job Modification Assistance Application

For use by an vocational counselor, employer, etc. to request modification for the injured workers job. This may involve tools and equipment that is purchased through L&I.



Formulario
F245-346-000

Otro(s) idioma(s):
Español
 
Vocational Training Plan Ownership Agreement for Tools and Equipment

Injured worker agrees to the ownership terms of the tools and/or equipment purchased as part of their training plan by L&I.



Formulario
F245-351-000

Otro(s) idioma(s):
Español
 
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):
Español
 
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 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 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
 
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):
Español
 
Queja por Discriminación de Seguro Industrial

Los empleados que piensan que han sido discriminados por su empleador pueden usar este formulario para presentar una queja.



Formulario
F262-009-999

Otro(s) idioma(s):
Inglés
 
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):
Español
 
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):
Español
 
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):
Español
 
Cuestionario Sobre la Pérdida del Sentido Auditivo en el Trabajo

Usada por el trabajador lesionado que ha presentado un reclamo por pérdida de audición para proporcionar información más específica referente a cómo ocurrió la pérdida de audición.  Esto es solicitado por el Gerente de reclamo y enviado al trabajador lesionado.



Formulario
F262-016-999

Otro(s) idioma(s):
Inglés
 
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 Program

Pamphlet/booklet: Describes the Preferred Worker Program and the benefits employers receive when hiring a preferred workers. Iin general, these are workers whose work-related injury or occupational disease prevents them from returning to their old job.



Publicación
F280-021-000

Otro(s) idioma(s):
Español
 
Programa con Incentivos para Reemplear Trabajadores Lesionados

Panfleto/folleto:  Describe el Programa con incentivos para reemplear trabajadores lesionados y los beneficios que reciben los empleadores cuando contratan trabajadores con el programa.  En general, estos son trabajadores cuyas lesiones o enfermedad ocupacional les impide regresar a su antiguo trabajo. 



Publicación
F280-021-999

Otro(s) idioma(s):
Inglés
 
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
 
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
 
Job Safety and Health Law / 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 Requerido:  Describe partes importantes sobre la Ley de Salud y Seguridad Industrial (WISHA, por su sigla en inglés), la cual proporciona seguridad y salud en el trabajo para los empleados de Washington.  Aviso:  Los empleadores en el estado de Washington deben colocar este cartel donde los trabajadores puedan verlo.  Al ordenar la versión impresa, usted recibirá un cartel de 22"x 17"que incluye ambos idiomas.

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



Cartel
F416-081-909
 
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



Publicación
F416-132-000

Otro(s) idioma(s):
Español
 
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
 
Office Ergonomics: Practical solutions for a safer workplace
Book: Provides information and tools to analyze office jobs, find problems and develop ergonomic solutions.

Publicación
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.

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

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:  Los empleadores tienen derecho a reportar las inquietudes relacionadas con la seguridad y la salud en el lugar de trabajo.  Este cartel describe  las "actividades protegidas" bajo la Ley de Salud y Seguridad Industrial de Washington (WISHA, por su sigla en inglés) y explica lo que debe hacer un empleado si él/ella ha sido castigado o despedido por ejercer sus derechos.  Obtenga consejos para imprimir carteles.



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
 
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.

Publicación
F417-207-000
 
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.



Publicación
F417-209-000

Otro(s) idioma(s):
Español
 
Mantenga a sus empleados seguros y trabajando

Panfleto/folleto:  Describe los beneficios de las consultas gratis para  empleadores que ofrece la División de Seguridad y Salud Ocupacional (DOSH, por su sigla en inglés) de L&I.  Estos servicios incluyen consultas de seguridad y/o higiene industrial, asistencia de ergonomía y recomendaciones sobre el manejo de riesgos en el sitio de trabajo.



Publicación
F417-209-999

Otro(s) idioma(s):
Inglés
 
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.

Publicación
F417-214-000
 
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):
Español
 
Presuntos Riesgos de Salud y Seguridad (Formulario de Queja de DOSH)

Los empleados usan este formulario de queja para reportar las condiciones de trabajo que ponen en peligro la seguridad y salud de los trabajadores.



Formulario
F418-052-999

Otro(s) idioma(s):
Inglés
 
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
 
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.



Publicación
F700-022-000

Otro(s) idioma(s):
Español
 
Adolescentes en el trabajo

Panfleto/folleto: Responde a preguntas que los empleadores, padres y adolescentes podrían tener cuando contratan trabajadores adolescentes (edades 14-17). Explica las reglas de trabajo no agrícolas, incluyendo los permisos necesarios, horas y condiciones de trabajo. Proporciona enlaces para otros recursos.



Publicación
F700-022-999

Otro(s) idioma(s):
Inglés
 
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):
Español
 
Instrucciones para el Registro de una Queja Sobre Salario Prevaleciente

Pídale a L&I que haga una investigación de un asunto relacionado con el salario prevaleciente que afecte a uno o más empleados.



Formulario
F700-146-999

Otro(s) idioma(s):
Inglés
 
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):
Español
 
Acuerdo entre Contratistas Agrícolas y Trabajadores

Acuerdo con los contratistas agrícolas y trabajadores sobre salarios de empleo y condiciones 



Formulario
F700-046-999

Otro(s) idioma(s):
Inglés
 
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
 
What Are Your Rights When You Work for a Farm Labor Contractor? / ¿Cúales son sus derechos cuando trabaja para un contratista de trabajadores agrícolas? (English/Spanish)

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.

Hoja de información:  Explica los derechos de los trabajadores cuando están empleados por un contratista agrícola.  Los temas cubiertos incluyen seguridad en el lugar de trabajo, descanso y períodos de comida y ayuda si se lesionan en el trabajo.



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

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

Obtenga consejos para imprimir carteles. 

 

 

 



Cartel
F700-074-909
 
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
 
Letter of Intent for School Enrollment
Use by a full-time student who is entitled to receive pension benefits. The student must be at least 18 years old and no older than 23 years old. This form is to prove the students intention to register in an accredited school during the next quarter/semester.

Formulario
F242-382-000

Otro(s) idioma(s):
Español
 
Young Workers in Agriculture / Trabajadores jóvenes 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.

Pamfleto/folleto:  Contesta muchas de las preguntas que tienen los empleadores y los trabajadores menores de edad sobre el empleo de menores.  Cubre las leyes de trabajo en la agricultura, incluyendo los permisos necesarios, horas y condiciones de trabajo para los trabajadores de 12-17 años de edad.



Publicación
F700-096-909
 
Small Business Liaison Info Card
Introduces L&I's Small Business Liaison and the services provided, along with information on subscribing to the e-newsletter, L&I News for Small Business.

Publicación
F101-088-000
 
Your Daily Record of Hours Worked / Su Registro de Horas Trabajadas (English/Spanish)

Pamphlet/booklet: A pocket-sized bilingual booklet to encourage agricultural workers to keep track of their daily work hours and earnings.

Panfleto/folleto: Un librito bilingüe de tamaño bolsillo para exhortar a los trabajadores agrícolas a mantener un registro de sus horas de trabajo diarias y de sus ingresos.



Publicación
F700-105-909
 
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.



Publicación
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
 
Authorization for Deposit of Payments / Autorización para Depósitos de Pagos (English/Spanish)

Used by pensioner to authorize L&I to deposit the pension payment to any designated financial institution. NOTE: F242-177-999 is the Direct Deposit Letter in Spanish.

Usado por un pensionado para autorizar a L&I para que deposite el pago de pensión en cualquier institución financiera designada.  AVISO: F242-177-999 es la carta para Depósito directo en español.



Formulario
F242-174-909

Otro(s) idioma(s):
Inglés
 
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 to Reopen Crime Victim Claim Due to Worsening of Condition

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



Formulario
F800-031-000

Otro(s) idioma(s):
Español
 
Online Electrical Services: Tools for Property Owners, Contractors and Electricians
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.

Publicación
F500-113-000
 
Application for Benefits - Crime Victims

Used by victims of a crime in Washington State to receive benefits for time lost from work, loss of financial support, medical or mental health treatment. The Spanish version of the instructions are online as F800-042-999.



Formulario
F800-042-000

Otro(s) idioma(s):
Español
 
New Elevator Installation Checklist

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



Formulario
F621-057-000
 
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
 
Request for Survivor Counseling Benefits / Solicitud para Beneficios de Apoyo para los Sobrevivientes (English/Spanish)  

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

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



Formulario
F800-057-909
 
Danger
Large lettering: DANGER. Get poster printing tips.

Cartel
FSP1-030-000

Otro(s) idioma(s):
Español
 
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
 
Danger / Cartel - PELIGRO (English/Spanish)

Large lettering: DANGER. Get poster printing tips.

En letras grandes: PELIGRO



Cartel
FSP1-030-999

Otro(s) idioma(s):
Inglés
 
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
 
Watch Where You Step
Large lettering: Watch Where You Step. Get poster printing tips.

Cartel
FSP1-055-000
 
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
 
Carta de Intención de Registro en una Escuela

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



Formulario
F242-382-999

Otro(s) idioma(s):
Inglés
 
Safety Comes Thru Job Training
A supervisor having a discussion with his crew. Get poster printing tips.

Cartel
FSP0-901-000
 





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