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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 Elective Coverage of Excluded Employments

Used by employers to request coverage of workers' compensation for non-mandatory employment. Shows a list of employment categories to choose from that are not included within the mandatory coverage of workers' compensation.



Formulario
F213-112-000
 
Workers' Compensation Insurance Manual

This manual covers Chapter 296-17 and 296-17A WAC. Topics covered are employer reporting requirements for workers' compensation; employer classification for workers' compensation; and rates and experience rating rules for workers' compensation.



Manual
F213-178-000
 
Corporate Officers

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



Publicación
F214-010-000
 
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
 
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. This information is part of the publication, Workers’ Compensation Record Keeping and Report Guides.



Publicación
F214-016-000
 
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
 
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
 
Application for Structured Settlement

This form is completed by injured workers or their representative to apply for a structured settlement.



Formulario
F240-002-000
 
Settling your L&I claim might be right for you: A new option for injured workers 53 or older

Pamphlet/booklet: Explains structured settlement and provides an overview of eligibility and the application and approval processes. The audience for this pamphlet is injured workers who might be eligible.



Publicación
F240-003-000

Otro(s) idioma(s):
Español
 

Settling your injured worker’s L&I claim: A new option for injured workers 53 and older

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



Publicación
F240-004-000
 
Structured Settlement Income and Expense Worksheet

This form is completed by the injured worker, or their representative in conjunction with an Application for Structured Settlement.



Formulario
F240-007-000
 
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
 
Work Status Form (formerly Worker Verification Form)

This form was previously called the Worker Verification Form. This is to be 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
 
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
 
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
 
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
 
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
 
Application to Reopen Claim due to Worsening Condition / Solictud para volver a abrir un reclamo (English/español)

Used by injured workers and doctors to apply to reopen an industrial injury or occupational disease claim that has been closed for longer than 60 days.

Usado por los trabajadores lesionados y doctores para volver a abrir un reclamo de lesión industrial o enfermedad ocupacional que ha estado cerrado por más de 60 días.



Formulario
F242-079-909

Otro(s) idioma(s):
Inglés
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
 
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 www.FileFast.Lni.wa.gov. Please note only medical providers may order this form from the Warehouse.



Formulario
F242-130-000

Otro(s) idioma(s):
Español
 
Report of Accident - Injured Worker Instructions - Spanish

This is a Spanish tranlation of the questions asked of the injured worker on the Report of Accident (ROA). This document also includes worker information translated into Spanish.



Formulario
F242-134-999
 
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
 
Notice to Employees -- If a Job Injury Occurs/Aviso a los empleados--si ocurre una lesión en el trabajo (English/español)

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
 
Notice of Occupational Disease or Infection

Used by medical providers to notify L&I that an occupational disease or infection has been diagnosed and that the worker has been advised that their condition may be work-related. This form can be used if the worker does not complete a Report of Accident or Occupational Disease (ROA) but should not be completed in place of an ROA.



Formulario
F242-243-000
 
Pension and Survivor Benefits in Washington State's Workers' Compensation Program / Beneficios de pensión y para sbrevivientes del Programa de compensación para trabajadores de Washington (English/español)

Pamphlet/booket: Answers the most common questions about pension and survivor benefits under Washington's workers' compensation program.

Folleto: Respuestas para las preguntas más comunes sobre pensión y beneficios para sobrevivientes bajo el Programa de compensación para los trabajadores de Washington.



Publicación
F242-352-909
 
How to Protest a Department of Labor and Industries Decision / Cómo protestar una decisión en su reclamo del Departamento de Labor e Industrias (English/español)

Fact sheet: Explains how an injured worker can protest decisions on his/her claim and gives deadlines for taking action.

Hoja de información:  Explica como un trabajador lesionado puede protestar las decisiones en su reclamo e indica límites para tomar acción.



Publicación
F242-363-909
 
Activity Prescription Form (APF)

This form is used by health-care providers to communicate an injured worker's status, physical capacities, inability to work (time-loss) and treatment plans.



Formulario
F242-385-000
 
Address Change Request for Injured Workers
Completed and signed by a State Fund injured worker to notify L&I of a change in address. All address changes must be submitted in writing and signed by the injured worker.

Formulario
F242-388-000

Otro(s) idioma(s):
Español
 
Application for Pension Benefits by Spouse or Children

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



Formulario
F242-391-000

Otro(s) idioma(s):
Español
 
Pension Benefits Questionnaire

Used by an injured worker who receives an order that states he or she is totally permanently disabled. This questionnaire must be completed in full and all necessary documents attached before his or her pension benefit options can be calculated.



Formulario
F242-393-000

Otro(s) idioma(s):
Español
 
Affidavit for Time Loss Compensation Benefits

Completed by injured workers contending eligibility for payment of back time loss benefits for a period that exceeds six months or $25,000. Injured workers requesting benefits for current time missed from work due to a work-related injury should use the F242-052-000 Worker Verification Form.



Formulario
F242-395-000

Otro(s) idioma(s):
Español
 
FileFast postcard handout for workers
Handout (4.25 x 6): Explains to workers why and how to file an accident report online or by phone following an injury; also reminds them to stay in contact with employer and L&I.

Publicación
F242-398-000
 
FileFast poster for workers
Poster (8.5 x 11): Explains to workers why and how to file an accident report online or by phone following an injury and reminds them to stay in contact with employer and L&I.

Cartel
F242-399-000
 
FileFast wallet card for workers
Wallet card (3.5 x 2): Reminds workers of FileFast web address and number for call center.

Publicación
F242-400-000
 
3 Things to Know about L&I's Medical Provider Network

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



Publicación
F242-406-000

Otro(s) idioma(s):
Español
 
Chemical Exposure Questionnaire Packet

Packet that contains:

F242-409-000 Chemical Exposure Questionnaire

F242-410-000 Worker Release for Union Dispatch Records

F262-005-000 Authorization to Release Information

Request for Social Security Earnings Information with the L&I address.



Formulario
F242-409-000

Otro(s) idioma(s):
Español
 
Worker Request for Union Dispatch Records

Worker Request for Union Dispatch Records



Formulario
F242-410-000

Otro(s) idioma(s):
Español
 
Workers’ Compensation Requirements for the Marijuana Industry

Brochure: Overview of workers' compensation requirements for the marijuana industry, including the use of volunteers and independent contractors. Also provides information on opening an account and how to report workers.



Publicación
F242-415-000
 
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
 
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.



Publicación
F243-005-000
 
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.



Publicación
F243-006-000

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
 
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
 
Independent Medical Exam Comments
Used by the injured worker to provide comments to L&I about their recent medical exam by an IME.

Formulario
F245-053-000

Otro(s) idioma(s):
Español
 
Frequently Asked Questions about Job Modifications
Fact sheet: Answers questions employers, workers and doctors may have about job modifications, including when to request a job-modification consultant and who pays for the costs involved.

Publicación
F245-057-000
 
Physical Therapy / Occupational Therapy Progress Report to Claim Managers

The physical / occupational therapist uses this report to identify the clinical goals and return to work objectives of the injured worker.



Formulario
F245-059-000
 
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
 
Statement for Pharmacy Services

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



Formulario
F245-100-000
 
CMS 1500

Used by providers to be reimbursed for services. It is NOT for use by injured workers to submit a claim to L&I.



Formulario
F245-127-000
 
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
 
Your Independent Medical Exam

Pamphlet/booklet: Answers the most common questions about independent medical exams and when and why an injured worker may be required to receive one. Includes the "IME Travel & Wage Reimbursement Request" form.



Formulario
F245-224-000

Otro(s) idioma(s):
Español
 
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
 
Pre-Job Accommodation Assistance Application

For use by a therapist or vocational provider to request job modification for an injured worker before the injured workers is employed, possibly in a retraining program. This may involve tools and equipment that is purchased through L&I.



Formulario
F245-350-000

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
 
Long Term Care Assessment Tool

You must mail or fax form. No emailed forms are accepted. This assessment tool is provided by L&I assessment to determine the medically appropriate level of care that will meet the Injured Worker’s needs, abilities and safety in a residential facility. This assessment is not intended as a substitute for DSHS annual assessment & treatment plan, which is the sole financial responsibility of the facility.



Formulario
F245-377-000
 
Hearing Aid Repair Authorization Fax Request

Hearing Aid Repair Authorization Requests. If you need to purchase or replace a hearing aid, fax all of the information required by Medical Aid Rules and Fee Schedule (MARFS) including the Hearing Services Worker Information (F245-049-000) to 360-902-6252.



Formulario
F245-384-000
 
F245-392-000 Resource Utilization Group (RUG) Residential Care Services for L&I Injured Workers (In place of MDS 3.0 beginning October 1, 2010.)
Filled out by the provider when they treat an injured worker. See web links below for: Latest payment amounts, Updates and corrections, and Review payment policy. For use in place of Minimum Data Set (MDS) 3.0 beginning October 1, 2010.

Formulario
F245-392-000
 
Provider Network Agreement
The provider network agreement for participation in the health care provider network for injured workers covered by Washington State Fund and self-insured employers.

Formulario
F245-397-000
 
Interpreter Services for Injured Workers and Crime Victims

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



Publicación
F245-412-000

Otro(s) idioma(s):
Español
 
Physical/Occupational/Massage Therapy Provider Hotline Service Authorization Request

This form is used by physical, occupational, and massage therapist to request additional visits for injured workers.



Formulario
F245-417-000
 
Department of Labor and Industries Home Modification Acknowledgement of Responsibilities

Used by both workers and bidding contractors to read, sign and submit to L&I to verify that they have read, understand and accept their respective responsibilities in the home modification process.



Formulario
F247-003-000

Otro(s) idioma(s):
Español
 
Electronic Billing Authorization

To authorize L&I to accept electronically submitted bills for services provided to injured workers (2 pages).



Formulario
F248-031-000
 
Out of Country Provider Application

This application is for providers outside the United States. Providers who treat injured workers must have a provider number to bill the department.



Formulario
F248-361-000

Otro(s) idioma(s):
Español
 
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
 
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.

Publicación
F250-006-000
 
Application for Limited Elective Coverage for Licensed Pony Riders

This form is used to provide free-agents the ability to obtain workers’ compensation insurance benefits.



Formulario
F250-026-000
 
Medical Examiners' Handbook

Book: A publication for independent medical examiners, attending doctors and consultants, this document contains guidelines, sample reports and billing procedures for preparing and conducting impairment ratings and independent medical exams in Washington's workers' compensation system. Beginning July 1, 2012, free Category I CME credits are available for completing the self-assessment associated with this handbook. Go to www.Imes.Lni.wa.gov and click on Medical Examiners Handbook for information on the exam. L&I and the authors have no financial interest or other relationship with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this document. Find a medical examiner.



Publicación
F252-001-000
 
Attending Doctor's Handbook

Note: The October 2012 update edition contains limited new information, including a summary of recent workers' compensation reforms. The inside pages remain the same as the 03-2005 edition. This handbook contains useful information to help providers who treat patients in the workers' compensation system. Physicians can obtain 3 hours of CE credit by completing an online self-assessment based on this handbook. 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.



Publicación
F252-004-000
 
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
 
Assessment Closing Report

Used by only private sector vocational rehabilitation providers to document vocational assessment to determine if a worker is employable based upon transferable skills.



Formulario
F252-029-000
 
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
 
Home Modification for Workers with Catastrophic Injuries

Fact sheet: Answers questions about the home modification benefit in Washington State's workers' compensation program, who qualifies, what L&I can pay, and where to get more information.



Publicación
F252-060-000
 
Home Modification for Workers with Catastrophic Injuries - Questions and Answers for Contractors

Fact sheet: Answers questions about the home modification benefit in Washington State's workers' compensation program and the bid process for contractors interested in this work.



Publicación
F252-061-000
 
Making the Best Treatment Choice for Your Chronic Low-back Pain
Fact sheet: Reviews the options that an injured worker with low-back pain should consider in determining the best treatment choice.

Publicación
F252-081-000
 
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
 
Claim Suppression Complaint

An injured worker may submit this form if their employer has suppressed their right to file an injury claim.



Formulario
F262-024-000

Otro(s) idioma(s):
Español
 
Targeting Fraud and Abuse in Washington State's Workers' Compensation Program: 2008 Report to the Legislature
Booklet/Pamphlet: Provides an overview of L&I's activities to deter and detect workers' compensation fraud and abuse by workers, employers and medical providers. Includes statistics on dollars collected and costs avoided.

Publicación
F262-032-000
 
Workers' Compensation Discrimination / Discriminación porque se lesionó en su trabajo (English/español)

Fact sheet: Explains workers' legal right to file a workplace injury claim and how to file a complaint if discrimination has occurred.

Hoja de información:  Explica el derecho legal de los trabajadores para presentar un reclamo de lesión en el lugar de trabajo y como presentar una queja si ocurre una discriminación.



Publicación
F262-249-909
 
Targeting Fraud and Abuse in Washington State's Worker's Compensation Program: 2005 Report to the Legislature
Booklet/pamphlet: Provides an overview of L&I's activities to deter and detect workers' compensation fraud and abuse by workers, employers and medical providers. Includes statistics on dollars collected and costs avoided.

Publicación
F262-251-000
 
Avoid Liability for Your Subcontractor's Unpaid Workers' Comp Premiums
Fact sheet: Tells construction contractors how to protect themselves from liability for their subcontractor's unpaid workers' compensation premiums.

Publicación
F262-262-000

Otro(s) idioma(s):
Español
 
Workers' Comp Fraud Hurts YOU
Pamphlet: Explains the impacts of workers' comp fraud and L&I's efforts to prevent and find fraud by workers, employers, contractors, and medical providers.

Publicación
F262-279-000
 
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
 
Plan Development Recommending Plan Approval 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 only if you are recommending Plan Approval. For all other closing reports, use Vocational Closing Report Routing Sheet (F252-027-000).

Formulario
F280-013-000
 
Assessing Your Ability to Work: Your Rights and Responsibilities
Booklet: Explains the basics of the assessment phase of vocational services to injured workers. L&I sends this booklet to injured workers when they are referred for assessment services.

Publicación
F280-017-000

Otro(s) idioma(s):
Español
 
Plan Development: What Are My Rights & Responsibilities?
Booklet: Explains the basics of the plan development phase of vocational services to injured workers. L&I send this booklet to injured workers when they are referred for plan development services. The assigned vocational rehabilitation counselor is required to review this booklet with the worker at their initial face-to-face meeting.

Publicación
F280-018-000

Otro(s) idioma(s):
Español
 
Carrying Out Your Vocational Plan: Your Rights and Responsibilities During Plan Implementation
Booklet: Explains the basics of the plan implementation phase of vocational services to injured workers. L&I sends this booklet to injured workers once the vocational plan they submitted is approved. Information about continuing with the vocational plan or selecting Option 2 to decline retraining is included.

Publicación
F280-019-000

Otro(s) idioma(s):
Español
 
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
 
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
 
Option 2 Vocational Benefits Training Enrollment Application and Verification

State fund workers who have selected Option 2 and closed their claim can use this form to apply for access to their Option 2 training funds. To seek reimbursement, use form F245-030-000 Statement for Retraining and Job Modification Services.



Formulario
F280-024-000

Otro(s) idioma(s):
Inglés/Español
 
Option 2 Vocational Benefits Training Enrollment Application/Solicitud y verificación del registro para capacitación de beneficios vocacionales opción 2 (English/español)

State fund workers who have selected Option 2 and closed their claim can use this form to apply for access to their Option 2 training funds. To seek reimbursement, use form F245-030-000 Statement for Retraining and Job Modification Services.

Los trabajadores bajo el Fondo estatal que han escogido la Opción 2 y que cerraron su reclamo pueden utilizar este formulario para solicitar acceso de los fondos de capacitación de la Opción 2.  Para solicitar un reembolso, utilice el formulario F245-030-999 Declaración de servicios de capacitación y servicios de modificación de trabajo.



Formulario
F280-024-909

Otro(s) idioma(s):
Inglés
 
On the Job Training Accountability Agreement

This form is for OJT training plans, and must be signed by the worker and VRC then sent in along with your training plan to L&I for approval. For non-OJT retraining plans, please refer to form F280-016-000.



Formulario
F280-029-000

Otro(s) idioma(s):
Español
 
Are You an Employer Who Can Provide On-the-Job Training?
Fact sheet: Explains how employers play an important role in helping injured or ill workers return to meaningful employment and a productive life by offering on-the-job training opportunities.

Publicación
F280-033-000
 
Vocational Questionnaire/Work History

Vocational Questionnaire/Work History for use by Vocational Providers serving injured workers.



Formulario
F280-038-000

Otro(s) idioma(s):
Español
 
Non-accredited or Unlicensed Training Provider Application Supplemental Requirements

Used by non-accredited or unlicensed training providers in order to be reviewed for approval to become a training provider for Washington injured workers. Must be submitted with the Provider Account Application (F248-011-000).



Formulario
F280-045-000
 
Referral to Labor and Industries /WorkSource Partnership Services

Used by private Vocational Providers  and Health Service Coordinators (HSCs) to refer injured workers to WorkSource



Formulario
F280-046-000
 
Preferred Worker Benefit Frequently Asked Questions

Fact sheet: Includes information regarding the benefits of Preferred Worker certification, answers to questions frequently asked by workers, phone and website contacts.



Publicación
F280-052-000

Otro(s) idioma(s):
Español
 
Workers' Guide to Hazardous Chemicals / Guía del trabajador para el uso de químicos (English/español)

Brochure: Explains workers' rights under Washington's Hazard Communication rule but does not fulfill an employer's legal obligation to provide information and training to employees.

Includes information for workers about working safety around hazardous chemicals and understanding warning labels.

Folleto:  Explica los derechos de los trabajadores bajo la ley de comunicación de riesgos químicos en el estado de Washington pero no satisface la obligación legal del empleador para proporcionar información y capacitación para los empleados.

Incluye información para los trabajadores sobre la seguridad al trabajar donde se usan químicos peligrosos y entender las etiquetas de advertencia.

The Spanish section of this publication is being revised and will be available in the future. / Estamos actualizando la sección en español de esta publicación y estará disponible en el futuro.



Publicación
F413-014-909
 
Poison Oak Poster / Cartel sobre el zumaque venenoso (English/español)

Full-color photographs of poison oak in different seasons help workers recognize and avoid the plant when working outdoors. Note: Poster will split over two pages if printed on 8.5" X 11" paper. Get poster printing tips.

Fotografías del zumaque venenoso a todo color en diferentes estaciones que ayudan a los trabajadores a reconocer y evitar contacto con la planta al trabajar al aire libre.  Aviso:  El cartel se dividirá en dos páginas si se imprime en papel de 8.5 x 11 pulgadas. Obtenga información sobre cómo imprimir carteles.



Cartel
F413-045-000
 
Protecting Yourself and Your Workers from Poison Oak and Ivy /Protejase usted mismo y a sus trabajadores contra el Zumaque Venenoso y la hiebra venenosa (English/Spanish)

Pamphlet/booklet: Discusses the effects of poison oak and ivy, where it is found in Washington State, how to control growth and protect workers from exposure.

Panfleto:  Discute los efectos del zumaque venenoso y la hiedra venenosa, dónde se encuentran en el estado de Washington, cómo controlar el crecimiento y proteger a los trabajadores contra la exposición a estas.



Publicación
F413-047-000
 
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
 
Worker and Community Right-to-Know Program
Fact sheet: Provides an overview of the Worker and Community Right-to-Know (RTK) Program authorized by legislation in 1986. Explains the RTK fees, education on hazardous substances that the fees support, who pays the fees and how they are calculated.

Publicación
F413-075-000
 
Safety Standards for WAC 296-45  -  Electrical Workers

Safety Standards for Electrical Workers, 296-45 WAC, consist of the requirements for safeguarding employees against electrical hazards in their workplace; requirements for electric equipment and wiring in locations classified as hazardous.



Manual
F414-032-000
 
Safety and Health Workshops

Pamphlet/Brochure: Introduces free workshops to help employers prevent workplace injuries and control workers' compensation costs. Includes course descriptions, and how to register.



Publicación
F416-036-000
 
Job Safety and Health Law / Ley de Seguridad y Salud en el Trabajo (English/español)

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 pulgadas 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
 
Office Locations Map

Fact sheet: Shows which L&I region serves which counties and the location of offices. Side Two lists the address and telephone number for each office.



Publicación
F101-100-000
 
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
 





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