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Master Business Application

Link is to the Master Business License online form: Required for employers who hire minors and is obtained by completing the Master Business Application. Also available from L&I warehouse.



Formulario
BLSF-700-028
 
Program Equal Employment Opportunity Activity Documentation

Used to record individual equal employment opportunity activities conducted by Apprenticeship Programs.



Formulario
F100-012-000
 
The Apprenticeship Advantage: Earn While You Learn!
Fact sheet: Introduces apprenticeship to younger people. Explains the benefits of apprenticeship, a program of study where apprentices earn wages while learning a skilled profession. Includes contact information for L&I's apprenticeship coordinators around the state.

Publicación
F100-022-000
 
Application for Apprenticeship

EXAMPLE ONLY: Example of an application to apply for an apprenticeship. Registered Apprenticeship Programs use their own forms. NOT TO BE USED TO REQUEST PLUMBER or ELECTRICAL TRAINEE CARD.



Formulario
F100-033-000
 
Washington State Apprenticeship Programs Catalog
Book: Provides an overview of apprenticeship, explains general requirements, lists the apprenticeship programs in Washington State and, and provides contact information. The version available online may contain more up-to-date information than the June 2012 printed edition.

Publicación
F100-041-000
 
Apprenticeship Applicant Register
Example: Used for tracking applicants for an apprenticeship program. Registered Apprenticeship Programs use their own forms.

Formulario
F100-045-000
 
Request for Approval of Proposed Standards

Request for new apprenticeship standards.



Formulario
F100-049-000
 
Journey Level Wage Rate from which apprentices' wages rates are computed.

Used to submit the Journey-level wage rate from which the apprentices' wage rate is computed. Form must be submitteed at least annually or sooner if the rates change.



Formulario
F100-050-000
 
Related Supplemental Instruction Hours

Used by Apprenticeship programs to submit related instruction hours to L&I Apprenticeship section. It is preferred that programs use the combined RSI/OJT reporting form. RSI Hours must be reported quarterly.



Formulario
F100-228-000
 
Request for Cancellation of Program

Used for cancelling an apprenticeship program.



Formulario
F100-303-000
 
Apprenticeship Complaint (Not for Apprenticeship Appeals)

Used to file a complaint on a apprenticeship program, committee, training agent, etc. NOT be used by Apprentices appealing Committee Decisions.



Formulario
F100-505-000
 
Request for Cancellation of New Apprenticeship Committee

To request a cancellation of a new apprenticeship committee which never has a "Request for New Standards" approved by the WSATC



Formulario
F100-510-000
 
Registered Apprenticeship Program Address/Mailing Information Update

Used by the Registered Apprenticeship Program to update their address or mailing information. (Note: This DOES NOT update your program standards information.) You should ensure that your address information in the Standards is correct.



Formulario
F100-512-000
 
Equal Employment Opportunity (EEO) Resource & Referral Update Form

Used by an organization to get on the Apprenticeship Program equal opportunity resources list or use to update their information on the list.



Formulario
F100-513-000
 
Log of Good Faith Effort Documentation

This is for Registered Apprenticeship Programs to record Good Faith Effort activities in accordance with their Registered Apprenticeship Standards (Equal Employment Opportunity Plan)



Formulario
F100-515-000
 
Related Supplemental Instruction / On-the-Job Training Hours

Used to track apprentices/trainees on-the-job training hours.



Formulario
F100-518-000
 
Apprenticeship Related Supplemental Instruction (RSI) Plan Review Glossary of Terms

Glossary of terms used with Apprenticeship Related Supplemental Instruction (RSI) Plan Review form and RSI Plan.



Formulario
F100-519-000
 
Apprenticeship Related Supplemental Instruction (RSI) Plan Review

Used by apprenticeship programs/sponsors as part of the process of getting new programs/standards/occupations approved.



Formulario
F100-520-000
 
Apprenticeship Related Supplemental Instruction (RSI) Plan Revew Review Criteria

Describes the process for getting approval of new or revised RSI for new apprenticeship programs/standards/occupations.



Formulario
F100-521-000
 
Training Agent Agreement and Understanding of Equal Employment Opportunity (EEO) Requirements of the Apprenticeship Committee - Alternate Selection Process

This should be signed by all employers who are Training Agents with Apprenticeship Programs that use an Alternate Selection Process. This also explains their obligations and rights as part of this process.



Formulario
F100-523-000
 
Apprenticeship Committee Representative Qualification Information Experience & Education History

Supplys the experience and education history of new committee members to ensure that they are qualified to be committee members. Used for New Standard submissions only.



Formulario
F100-528-000
 
Using Apprentices on Public Works and Other Projects
Pamphlet: Provides a quick overview of the rules for using apprentices on public works projects, including apprentice utilization. Also describes the benefits of apprenticeship and where to get more information.

Publicación
F100-529-000
 
Apprenticeships For Tribal Members

 

Brochure: Designed for tribal members, this brochure provides an overview of apprenticeship. Topics include the benefits of apprenticeship, career options, how to apply and contact information.

 



Publicación
F100-532-000
 
Access Authorization for External Access to Apprenticeship Registration and Tracking System (ARTS)

Form must be filled out to request access to Apprenticeship Registration and Tracking System (ARTS).



Formulario
F100-535-000
 
Employers’ Guide to Workers’ Compensation Insurance in Washington State

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



Publicación
F101-002-000
 
Request for Public Records

To request public records from Washington State Dept. of Labor and Industries. You can order an earlier version from the LNI warehouse until stock is exhausted.



Formulario
F101-009-000
 
Authorization to Release Claim Information

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



Formulario
F101-010-000

Otro(s) idioma(s):
Español
 
Request for Claim Information

Used by workers, workers' representatives, employers or employers' representatives to request claim information from L&I.



Formulario
F101-010-111
 
Autorización para proveer información de reclamos

Usado por el trabajador para designar a una persona(s) como representante(s) autorizado(s) del reclamo del trabajador.  Un representante autorizado puede obtener acceso a la información de reclamo.



Formulario
F101-010-999

Otro(s) idioma(s):
Inglés
 
Workplace Posters: Required and Recommended
Fact sheet: Lists posters that Washington State and federal agencies require or recommend employers post in their places of business. The URLs for posters available online and and telephone numbers to request printed posters are also provided. Also includes online resources and contact numbers for state agencies that issue posters.

Publicación
F101-054-000
 
Your Privacy Is Important to Us / Su privacidad es importante para nosotros (English/español)

Fact sheet: Serves as L&I's official privacy notice. States how L&I may use and share the pesonal information it collects. It also informs the public how they can file a complaint if they believe L&I has misused or inappropriately disclosed their personal information.

Hoja de información:  Esta es la notificación oficial de privacidad de L&I.  Establece como L&I podría usar y compartir la información personal que recibe  También le informa al público sobre como puede presentar una queja si cree que L&I ha comprometido o entregado inapropiadamente su información personal.  



Publicación
F101-055-909
 
What Are Your Rights as a Worker? (English/Russian)
Fact sheet: Provides a brief overview of the worker rights administered by the Department of Labor and Industries. These include certain employment-related rights and rights pertaining to workplace safety and workers' compensation benefits.

Publicación
F101-061-404

Otro(s) idioma(s):
Inglés/កម្ពុជា
Inglés/한국의
Inglés/Español
Inglés/Việt
 
What Are Your Rights as a Worker? (English/Vietnamese)
Fact sheet: Provides a brief overview of the worker rights administered by the Department of Labor and Industries. These include certain employment-related rights and rights pertaining to workplace safety and workers' compensation benefits.

Publicación
F101-061-505

Otro(s) idioma(s):
Inglés/កម្ពុជា
Inglés/한국의
Inglés/русский
Inglés/Español
 
What Are Your Rights as a Worker? (English/Cambodian)
Fact sheet: Provides a brief overview of the worker rights administered by the Department of Labor and Industries. These include certain employment-related rights and rights pertaining to workplace safety and workers' compensation benefits.

Publicación
F101-061-606

Otro(s) idioma(s):
Inglés/한국의
Inglés/русский
Inglés/Español
Inglés/Việt
 
What Are Your Rights as a Worker? (English/Korean)
Fact sheet: Provides a brief overview of the worker rights administered by the Department of Labor and Industries. These include certain employment-related rights and rights pertaining to workplace safety and workers' compensation benefits.

Publicación
F101-061-707

Otro(s) idioma(s):
Inglés/កម្ពុជា
Inglés/русский
Inglés/Español
Inglés/Việt
 
What Are Your Rights as a Worker? / ¿Cuáles son sus derechos como trabajador? (English/español)

Fact sheet: Provides a brief overview of the worker rights administered by the Department of Labor and Industries. These include certain employment-related rights and rights pertaining to workplace safety and workers' compensation benefits.

Hoja de información: Proporciona un resumen de los derechos de los trabajadores administrados por el Departamento de Labor e Industrias. Estos incluyen algunos derechos relacionados con el empleo y derechos con la seguridad en el lugar de trabajo y beneficios de compensación para los trabajadores. 



Publicación
F101-061-909

Otro(s) idioma(s):
Inglés/កម្ពុជា
Inglés/한국의
Inglés/русский
Inglés/Việt
 
Guía para el contratista independiente - Una guía detallada para contratar contratistas independientes en el estado de Washington

Folleto: Una guía detallada para contratar contratistas independientes en el estado de Washington.  Esta publicación es una guía general para ayudarlo a entender cómo y cuándo el Departamento de Labor e Industrias aplica las leyes de compensación para los trabajadores a los contratistas independientes.



Publicación
F101-063-999

Otro(s) idioma(s):
Inglés
 
2005 Annual Report - Department of Labor & Industries

Provides a statistical overview of results achieved in fiscal year 2005 (July 1, 2004, through June 30, 2005), budget information and a narrative introduction to the Department of Labor and Industries.



Publicación
F101-068-000
 
If Family Members Work for You, Know Your Obligations (English/Thai)

Fact sheet: Provides an overview and resources to know your obligations when you have family members working for you. Relatives, including children, must be treated as employees with the same rights as any other paid worker in the state of Washington.



Publicación
F101-077-303

Otro(s) idioma(s):
Inglés/中国的
Inglés/한국의
Inglés/русский
Inglés/Español
Inglés/Việt
 
If Family Members Work for You, Know Your Obligations (English/Russian)
Fact sheet: Provides an overview and resources to know your obligations when you have family members working for you. Relatives, including children, must be treated as employees with the same rights as any other paid worker in the state of Washington.

Publicación
F101-077-404

Otro(s) idioma(s):
Inglés/中国的
Inglés/한국의
Inglés/Español
English/Thai
Inglés/Việt
 
If Family Members Work for You, Know Your Obligations (English/Vietnamese)
Fact sheet: Provides an overview and resources to know your obligations when you have family members working for you. Relatives, including children, must be treated as employees with the same rights as any other paid worker in the state of Washington.

Publicación
F101-077-505

Otro(s) idioma(s):
Inglés/中国的
Inglés/한국의
Inglés/русский
Inglés/Español
English/Thai
 
If Family Members Work for You, Know Your Obligations (English/Korean)
Fact sheet: Provides an overview and resources to know your obligations when you have family members working for you. Relatives, including children, must be treated as employees with the same rights as any other paid worker in the state of Washington.

Publicación
F101-077-707

Otro(s) idioma(s):
Inglés/中国的
Inglés/русский
Inglés/Español
English/Thai
Inglés/Việt
 
If Family Members Work for You, Know Your Obligations (English/Chinese)
Fact sheet: Provides an overview and resources to know your obligations when you have family members working for you. Relatives, including children, must be treated as employees with the same rights as any other paid worker in the state of Washington

Publicación
F101-077-808

Otro(s) idioma(s):
Inglés/한국의
Inglés/русский
Inglés/Español
English/Thai
Inglés/Việt
 
If Family Members Work for You, Know Your Obligations / Conozca sus obligaciones cuando miembros de su familia trabajan para usted (English/español)

Fact sheet: Provides an overview and resources to know your obligations when you have family members working for you. Relatives, including children, must be treated as employees with the same rights as any other paid worker in the state of Washington.

Hoja de información:  Proporciona un resumen y recursos para conocer sus obligaciones cuando tiene miembros de la familia trabajando para usted.  Los familiares, incluyendo los niños, deben ser tratados como empleados con los mismos derechos que cualquier otro empleado pagado en el estado de Washington.



Publicación
F101-077-909

Otro(s) idioma(s):
Inglés/中国的
Inglés/한국의
Inglés/русский
English/Thai
Inglés/Việt
 
2006 Annual Report - Department of Labor & Industries
Provides a statistical overview of results achieved in fiscal year 2006 (July 1, 2005, through June 30, 2006), budget information and a narrative introduction to the Department of Labor & Industries.

Publicación
F101-078-000
 
Applying for Your Washington Business License: A Step-by-Step Guide
Pamphlet: Concise, easy-to-read pamphlet that explains the steps to apply for a business license and what to do if you plan to employ workers. Includes how to apply to be a registered construction contractor.

Publicación
F101-079-000

Otro(s) idioma(s):
Español
 
Solicitando su licencia de negocio en Washington: una guía detallada

Volante: Un documento breve y fácil de leer que explica los pasos a seguir para solicitar una licencia de negocio y lo que necesita hacer si planea contratar empleados. Incluye cómo presentar una solicitud para registrarse como contratista de construcción.



Publicación
F101-079-999

Otro(s) idioma(s):
Inglés
 
2007 Annual Report - Department of Labor & Industries

Provides a statistical overview of results achieved in fiscal year 2007 (July 1, 2006, through June 30, 2007), budget information and a narrative introduction to the Department of Labor & Industries.



Publicación
F101-080-000
 
2008 Annual Report for the Washington State Fund: Washington's State-run Workers' Compensation Program

Book: Introduces Washington State's Workers' Compensation Program, including rate-setting and investment policies, financial statement overview, and services available to help employers control workers' comp costs.



Publicación
F101-086-000
 
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
 
2008 Annual Report - Department of Labor & Industries

Provides a statistical overview of operations in fiscal year 2008 (July 1, 2007, through June 30, 2008), budget information and a summary of accomplishments during the fiscal year.



Publicación
F101-089-000
 
Plan for and Pay Your Taxes
Information card: Introduces Washington State's 28-minute DVD that covers state business taxes and workers' compensation premiums and provides information on how to file.

Publicación
F101-091-000
 
Plan for and Pay Your Taxes DVD

DVD: Covers state business taxes and workers' compensation premiums and provides information on how to file. This 28-minute DVD can help employers plan ahead and obtain more information.



DVD
F101-091-034
 
Challenging Times Demand Our Best
Booklet: Describes how L&I is making changes, both big and small, to better serve our customers and operate efficiently. Three areas of focus are fighting fraud, putting customers first and cutting costs. Features stories about three customers L&I has helped.

Publicación
F101-095-000
 
Strategic Plan
Booklet: Explains the strategic direction of the Department of Labor & Industries. Includes a message from the director, goals, objectives and strategies.

Publicación
F101-099-000
 
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
 
An Employer's Intro to L&I

Info card: Provides information on the Employer's Intro to L&I workshop, including statewide schedule of workshops. Designed for employers and managers, the workshop covers a number of topics, including workers' compensation insurance, workplace safety, and overtime.



Publicación
F101-101-000
 
Challenges and Change: Managing and Innovating through The Great Recession — L&I from 2005-2012

Booklet: Discusses the impact of the Great Recession on L&I’s programs and highlights accomplishments from 2005 to 2012.



Publicación
F101-102-000
 
Department of Labor & Industries Organizational Chart

Fact Sheet: Shows divisions, programs and organizational structure of the Washington State Department of Labor & Industries (L&I).



Publicación
F101-170-000
 
Labor and Industries Facility Use Application and Agreement for Government Agencies

Use this form if you are a government agency wanting to use the L&I facility located at 7273 Linderson Way SW; Tumwater, WA. (4 pages)



Formulario
F120-097-000
 
Application to Establish an Factory Assembled Structure Deposit Account with the Dept. of Labor and Industries

Use to establish a factory assembled structure (FAS) deposit account. FAS deposit accounts are for businesses or other entities that are not currently licensed or registered with L&I as electrical or construction contractors but are legally required to purchase work permits from L&I. (3 pgs)



Formulario
F120-116-000
 
Protecting Washington Workers / Protegiendo a los trabajadores de Washington (English/español)

DVD: An innovative tool to teach Spanish-speaking workers about workplace rights while introducing English terminology.

DVD: Una herramienta innovadora para enseñarle a los trabajadores que hablan español sobre los derechos laborales mientras se presenta terminología en inglés.



DVD
F130-004-909
 
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
 
Your Premium Dollars at Work (2011)

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



Publicación
F200-019-000
 
Your Premium Dollars at Work (2012)

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



Publicación
F200-020-000
 
Your Premium Dollars at Work (2013)

Pamphlet/booklet: Provides information about the programs and services financed with workers' compensation premium dollars, along with statistics such as number of claims, demographics of claims and the most frequent types of injuries during FY2013 (year ending June 30, 2013). Includes narrative about workers' compensation reforms.



Publicación
F200-022-000
 
Your Premium Dollars at Work (2014)

Pamphlet/booklet: Provides information about the programs and services financed with workers' compensation premium dollars, along with statistics such as number of claims, demographics of claims and the most frequent types of injuries during FY2014 (year ending June 30, 2014). Includes narrative about workers' compensation reforms.



Publicación
F200-023-000
 
Application for Self-Insurance Certification

Used by employers to apply for self-insurance certification.



Formulario
F207-001-000
 
Self-Insurer Accident Report (SIF-2)

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



Formulario
F207-002-000
 
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. This form file now includes the instructions, which used to be a separate form number F207-011-111.



Formulario
F207-011-000
 
Self-Insured Employers' Medical Only Claim Closure Order and Notice

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



Formulario
F207-020-111

Otro(s) idioma(s):
Español
 
Notificación de decisión de cierre para reclamos únicamente médicos para empleadores autoasegurados

Usada solamente por los empleadores autoasegurados o sus representantes, esta es una notificación legal para un trabajador lesionado indicando que su reclamo está cerrado con beneficios médicos solamente.  Esta orden se usa solamente cuando no se ha pagado compensación de tiempo perdido ni tampoco indemnización por discapacidad parcial permanente.



Formulario
F207-020-999

Otro(s) idioma(s):
Inglés
 
Provider's Initial Report (PIR)

Used by medical providers when reporting initial treatment for an industrial injury or occupational disease for a self-insured claim. The paper version dated 10-2012 is still valid, as is the 01-2014 word fillable version.

Medical providers treating self-insured workers, self-insured businesses, or their third party claims administrators can access this form one of two ways:

  1. Download the Microsoft (MS) Word form and the PDF file with instructions:

           The first file is the PDF instructions.

           The second file is an Office 2003 MSWord document ending in .doc.

           The third file is an Office 2007/2010 version, ending in .docx.

2.  Order paper copies of this form by clicking the “order it” button.



Formulario
F207-028-000
 
Notice to Employees -- Self-Insurance / Aviso a los empleados -- Seguro industrial propio (English/español)

Required poster for self-insured businesses: Outlines what a worker employed by a self-insured business should do if a work-related injury or illness occurs. Note: Self-insured employers must display this poster where workers can see it.

Cartel requerido: para los negocios autoasegurados, describe lo que un trabajador empleado por un negocio autoasegurado debe hacer si le ocurre una lesión o enfermedad relacionada con el trabajo. Aviso: Los empleadores autoasegurados deben colocar este cartel donde los empleados puedan verlo.



Cartel
F207-037-909
 
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
 
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
 
Notificación de decisión de cierre para reclamos de tiempo perdido para empleadores autoasegurados

Usada solamente por los empleadores autoasegurados o sus representantes, esta es una notificación legal para un trabajador lesionado indicando que su reclamo está cerrado.  Esta orden se usa solamente cuando se ha pagado compensación de tiempo perdido pero no se está pagando una indemnización por discapacidad parcial permanente.



Formulario
F207-070-999

Otro(s) idioma(s):
Inglés
 
Employers' Guide to Self-Insurance in Washington State

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



Publicación
F207-079-000
 
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
 
Guía de beneficios de Compensación para los Trabajadores: para los empleados de empresas autoaseguradas

Folleto: Explica a los empleados de negocios autoasegurados sus derechos y responsabilidades bajo la ley de seguro industrial.  Describe los beneficios y como  presentar un reclamo.



Publicación
F207-085-999

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

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



Formulario
F207-095-000
 
Preparing for Your Self-Insurance Audit

Pamphlet/booklet: Helps self-insured employers understand and prepare for an audit.



Publicación
F207-110-000
 
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
 
Transfer of Attending Provider Form for Self Insured Workers

This form is used by self-insured injured workers who want to transfer their medical care.  Self-insured workers should complete the form and send it to their employer or their Third Party Representative.



Formulario
F207-114-000

Otro(s) idioma(s):
Español
 
Formulario para trasferencia de proveedor principal para trabajadores autoasegurados

Formulario: Es utilizado por los trabajadores autoasegurados que desean transferir su cuidado médico. Los trabajadores autoasegurados deben completar este formulario y enviarlo a su empleador o a su Representante de Terceros.



Formulario
F207-114-999

Otro(s) idioma(s):
Inglés
 
Annual Supplemental Surety Information

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



Formulario
F207-125-000
 
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
 
Schedule of Future Payments for the Balance of the Permanent Partial Disability Award

Used by Self-Insured companies to document future payments for the balance of the Permanent Partial Disability Award.



Formulario
F207-162-000
 
SIF-4 Self Insured Employer's Request for Denial of Claim
Used by self-insured employers or their representatives to notify an injured worker that the employer or representative is requesting that L&I deny their claim.

Formulario
F207-163-000
 
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
 
Notificación de decisión de cierre con discapacidad parcial permanente para empleadores autoasegurados -DISCAPACIDAD PARCIAL PERMANENTE (PPD) - CON TIEMPO PERDIDO (NTL)

Usada solamente por los empleadores autoasegurados o sus representantes.  Esta es una notificación legal para un trabajador lesionado indicando que su reclamo está cerrado.  Esta orden se usa solamente cuando se ha pagado compensación de tiempo perdido y también se está pagando una indemnización por discapacidad parcial permanente.



Formulario
F207-164-999

Otro(s) idioma(s):
Inglés
 
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
 
Notificación de decisión de cierre con discapacidad parcial permanente para empleadores autoasegurados - DISCAPACIDAD PARCIAL PERMANENTE (PPD) - SIN TIEMPO PERDIDO (NTL)

Usada solamente por los empleadores autoasegurados o sus representantes, esta es una notificación legal para un trabajador lesionado indicando que su reclamo está cerrado.  Esta orden se usa solamente cuando no se ha pagado compensación de tiempo perdido pero se está pagando una indemnización por discapacidad parcial permanente.



Formulario
F207-165-999

Otro(s) idioma(s):
Inglés
 
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
 
Self-Insurance Certification Questionnaire

Used by employers applying to become self-insured to describe their proposed workers' compensation program.



Formulario
F207-176-000
 
Self-Insurance Vocational Reporting Form

Used by self-insured employers and their representatives to report to L&I an injured worker's eligibility for vocational services or ability to work. This replaces F207-121-000 Employability Assessment Report (EAR).



Formulario
F207-190-000
 
Self Insurance Continuing Education Report of Course Completion

Used by department-approved claims administrators to report course completion for obtaining continuing education credit.



Formulario
F207-191-000
 
Self Insurance Continuing Education Sponsor/Instructor Application for Course Approval

Used by sponsors or instructors of continuing education courses, when requesting the department assign credit to a course so that department-approved claims administrators who attend can earn credit toward recertification under the Self Insurance Continuing Education program.



Formulario
F207-192-000
 
Self-Insurance Electronic Data Reporting System (SIEDRS) Enrollment Form
Used by self-insured employers and third party administrators to enroll for participation in the Self Insurance Electronic Data Reporting System (SIEDRS). F207-197-000 is SIEDRS (Self-Insurance Electronic Data Reporting System) Data Change Request.

Formulario
F207-193-000
 
Self-Insurance Electronic Data Reporting System (SIEDRS): Enrollment Package 2.0

Book: Explains the technical requirements for participating in SIEDRS, the Self-Insurance Electronic Data Reporting System.



Publicación
F207-194-000
 
SIEDRS (Self-Insurance Electronic Data Reporting System) Data Change Request

This is a data change request form. F207-193-000 is the Self-Insurance Electronic Data Reporting System (SIEDRS) Enrollment Form



Formulario
F207-197-000
 
Help for Injured Workers of Self-Insured Businesses
Information card: Introduces the Office of the Ombudsman for Self-Insured Injured Workers. The ombudsman is appointed by the Governor to serve as an independent advocate for the rights of injured workers of self-insured employers.

Publicación
F207-201-000

Otro(s) idioma(s):
Español
 
Ayuda para trabajadores lesionados de empresas autoaseguradas

Tarjeta de información:  Es una introducción a la Oficina del Defensor (Ombudsman en inglés) para trabajadores lesionados autoasegurados.  El defensor es nombrado por el Governador para servir como un defensor independiente de los derechos de los trabajadores lesionados de empleadores autoasegurados.



Publicación
F207-201-999

Otro(s) idioma(s):
Inglés
 
Your Independent Medical Exam: For Employees of Self-Insured Businesses
Pamphlet: Answers the most common questions about when and why an injured worker may be required to attend an independent medical exam. Includes the "IME Travel & Wage Reimbursement Request" form. This publication is for use only by self-insured businesses and their workers.

Publicación
F207-202-000

Otro(s) idioma(s):
Español
 
Su examen médico independiente: para empleadores de negocios autoasegurados

Folleto: Contesta las preguntas más comunes sobre cuándo y por qué puede requerirse que un trabajador lesionado asista a un examen médico independiente.  Incluye el Formulario examen médico Independiente (IME, por su sigla en inglés) Solicitud para el reembolso de gastos de viaje y salario.  Esta publicación es para uso solamente de las empresas autoaseguradas y sus trabajadores.



Publicación
F207-202-999

Otro(s) idioma(s):
Inglés
 
Self-Insurance Continuing Education Application for Course Approval and Attendance

Used by Certified Claims Administrators to apply for continuing education credits for a course attended that has not been approved for credits.



Formulario
F207-206-000
 
Self-Insurance Medical Provider Billing Dispute form

A form for Providers to submit disputes to the department regarding payment of medical provider bills



Formulario
F207-207-000
 
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
 
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

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. Online sample is not available.



Formulario
F212-055-000
 
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
 
Quarterly Reporting for Drywall

Used by drywall employers as a guide to completing quarterly and supplemental reports. This includes filled out samples of F212-050-000 and F212-051-000.



Formulario
F212-224-000

Otro(s) idioma(s):
Español
 
Reporte trimestral para la industria de tabla de yeso

Usado por los empleadores de tabla de yeso como una guía para completar los informes trimestrales y suplementarios.  Esto incluye ejemplos para completar el formulario Número F212-050-000 y el F212-051-000.



Formulario
F212-224-999

Otro(s) idioma(s):
Inglés
 
Washington Workers Insured Out-of-State: Employer’s Supplemental Quarterly Report for Workers’ Compensation

The purpose of 212-233-000 Supplemental reporting form is to allow employers to report out-of-state wages and hours as per the requirement in WAC 296-17-25203(8).



Formulario
F212-233-000
 
Application for out of State Supplemental Reporting

The purpose of form 212-234-000 -Out of state applications- is to provide a means for an employer to formally request to receive the out-of-state supplemental report for a specific year and state. The form will also allow the department to convey out-of-state reporting requirements and to obtain information needed by the department to set a business up for supplemental reporting.



Formulario
F212-234-000
 
Instructions for completing the Workers' Compensation Employer's Quarterly Report

Instructions for completing the Workers' Compensation Employer's Quarterly Report. A sample of the form F212-055-000 is also available on the internet.



Formulario
F212-239-000
 
Sports Player Coverage Agreement

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



Formulario
F212-242-000
 
Five Steps to File
Flyer: Reviews the steps for filing workers' compensation quarterly reports online and lists the filing due dates.

Publicación
F212-243-000
 
QuickFile: Workers' Compensation Quarterly Report Filing Made Easy!

Rack card: Information to help employers file their Workers' compensation quarterly report online. Includes filing webpages links and deadlines.



Publicación
F212-244-000
 
Taxi-for-hire Vehicle Reporting Requirements
Fact sheet: Provides information for the for-hire industry about mandatory coverage for all for-hire drivers. Includes the different reporting methods and due dates of quarterly reports.

Publicación
F212-245-000
 
Monthly Supplemental Report for Manual Logging

Used by employers enrolled in the Logger Safety Initiative (LSI) to report manual logging hours monthly.



Formulario
F212-246-000
 
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
 
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
 
The ABCs of Classifications in Washington
Book: Aids in understanding Washington State's workers' compensation classification system and how classifications are applied to different types of businesses.

Publicación
F213-022-000
 
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 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
 
Application for Exclusion/Inclusion - Mandatory Coverage (Family Farm)

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



Formulario
F213-113-000
 
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
 
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
 
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
 
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
 
Notice of Completion of Public Works Contract

This is the form used by public agencies to request L&I's approval to release retainage. All contractors are to be listed on the request form with their associated affidavit id number.  Notices received without affidavit id numbers or incomplete information will not be processed and will be returned to the awarding agency. The first EXCEL document is in Office 2007 format. The second file, with the same title, is in Office 2003 format.



Formulario
F215-038-000
 
Financial Statement Sole Proprietors and Individuals

Requesting Financial Information for Sole Proprietors and/or Individuals.



Formulario
F215-039-000
 
Financial Statement Businesses

Requesting Financial Information for Corporations, LLC and Partnerships.



Formulario
F215-040-000
 
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
 
Group vs. Individual Retrospective Rating Participation
Fact sheet: Provides information to employers interested in the Retrospective Rating Program who want to compare group vs. individual participation. Explains the differences in minimum premium amount, fees, services, refund potential, choice, and risk. Also includes contact information for enrolling.

Publicación
F225-016-000
 
Retrospective Rating Enrollment Decisions
Fact sheet: Information for employers regarding choices they should make when enrolling in the Retrospective Rating (Retro) program including plan type, single-loss limit and upper and lower loss-ratio limits.

Publicación
F225-017-000
 
Evaluating Retro Groups

Fact sheet: Provides information to employers who are considering joining a Retrospective Rating (Retro) group and how to choose one that best fits the need of their company. Explains the process for enrollment, deadlines, group eligibility, assessment, distribution of funds, dues, fees, services, and exit clauses.



Publicación
F225-019-000
 
Settling your L&I claim might be right for you: A new option for injured workers over 55

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
 
Llegar a un acuerdo sobre su reclamo de L&I puede ser lo correcto para usted - Una nueva opción para los trabajadores lesionados que tienen más de 55 años de edad (English/español)

Folleto: Explica el acuerdo sobre beneficios de compensación para trabajadores y proporciona un resumen de los requisitos que debe reunir y el proceso de solicitud y aprobación.  La audiencia para este folleto son los trabajadores lesionados los cuales pueden tener derecho a un acuerdo.



Publicación
F240-003-999

Otro(s) idioma(s):
Inglés
 
Settling your injured worker’s L&I claim: A new option for injured workers over 55

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
 
Formulario de estado de empleo (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
 
Verificación de registro en la escuela

Usada por un estudiante y un oficial de escuela cada trimestre para verificar el registro en la escuela.



Formulario
F242-055-999

Otro(s) idioma(s):
Inglés
 
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
 
Encursta para la Evaluacion de los Daños

Sus respuestas a estas preguntas serán utilizadas para ayudar a evaluar sus daños si se presenta un reclamo indicando que un tercero es responsable por los daños.



Formulario
F242-067-999

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
 
Occupational Disease Work History - Continuation

This is a continuation page to the Occupational Disease Work History (F242-071-000) to add additional work history.



Formulario
F242-071-111

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
 
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
 
Solicitud para reabrir un reclamo debido al empeoramiento de la condición 

Usada por los trabajadores lesionados y doctores para solicitar la reapertura de un reclamo de lesión industrial o enfermedad ocupacional que ha estado cerrado por más de 60 días.



Formulario
F242-079-999

Otro(s) idioma(s):
Inglés
Inglés/Español
 
Beneficios de compensación para los trabajadores: una guía para los trabajadores lesionados

Folleto: Explica los derechos y responsabilidades de los trabajadores bajo la Ley de Seguro Industrial.  Describe beneficios y cómo presentar un reclamo.  Aviso: El documento fue anteriormnte titulado, Guía de beneficios del seguro industrial para los trabajadores.  



Publicación
F242-104-999

Otro(s) idioma(s):
Inglés
 
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
 
Employment History Form

Used to provide your employment history for the past three years, including self-employment and volunteer work.

Please start with your most recent job and work backwards. Please list any gaps or interruptions in your work history.  If you were unemployed at any time, please explain why.  Did you apply for (or receive) unemployment benefits during the time period? If yes, what dates did you receive unemployment benefits?  Did you seek employment during the time period?  If no, why didn’t you seek employment?



Formulario
F242-109-000

Otro(s) idioma(s):
Español
 
Formulario de historial de empleo

Usado por el trabajador lesionado para reportar su historial de empleo y el salario de cada trabajo durante los últimos tres años



Formulario
F242-109-999

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
 
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, notarizarse 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 dependientes 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, notarizarse 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, notarizarse 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 / Autorización para depósitos de pagos (English/español)

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: El número del formulario F242-177-999 es la carta para depósito directo en español.



Formulario
F242-174-909

Otro(s) idioma(s):
Inglés
 
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
 
Application for Loss of Earning Power (LEP) - Compensation Medical

Completion of this form is not a guarantee of benefits. Payment of benefits will be decided by your claim manager.



Formulario
F242-208-000

Otro(s) idioma(s):
Inglés/Español
Español
 
Application for Loss of Earning Power Compensation Medical / Solicitud para compensación por reducción de ingresos (médicos) (English/Spanish)

Completion of this form is not a guarantee of benefits. Payment of benefits will be decided by your claim manager.

El hecho de completar este formulario no es una garantía para recibir beneficios.  Los pagos de beneficios lo decidirá su gerente de reclamo.



Formulario
F242-208-909

Otro(s) idioma(s):
Inglés
Español
 
Solicitud para compensación por reducción de ingresos (médico)

El completar este formulario no es una garantía para recibir beneficios.  El pago de beneficios lo decidirá su gerente de reclamo.



Formulario
F242-208-999

Otro(s) idioma(s):
Inglés
Inglés/Español
 
Application for Loss of Earning Power (LEP) - Vocational

Completion of this form is not a guarantee of benefits. Payment of benefits will be decided by your claim manager.



Formulario
F242-209-000

Otro(s) idioma(s):
Inglés/Español
Español
 
Application for Loss of Earning Power Vocational / Solicitud para compensación por reducción de ingresos (Vocacionales) (English/Spanish)

Completion of this form is not a guarantee of benefits. Payment of benefits will be decided by your claim manager.

El hecho de completar este formulario no es una garantía para recibir beneficios.  Los pagos de beneficios lo decidirá su gerente de reclamo.



Formulario
F242-209-909

Otro(s) idioma(s):
Inglés
Español
 
Solicitud para compensación por reducción de ingresos (Vocacional)

Completando este formulario no es una garantía para recibir beneficios.  El pago de beneficios lo decidirá su gerente de reclamo.



Formulario
F242-209-999

Otro(s) idioma(s):
Inglés
Inglés/Español
 
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
 
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
 
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
 
Independent Medical Exam Doctor's Estimate of Physical Capacities

IME Doctor’s Estimate of Physical Capacities: For use by independent examiners when asked to estimate physical capacities as part of an IME requested by the department.



Formulario
F242-387-000
 
Solicitud para cambio de dirección para trabajadores lesionados

Para ser completada y firmada por un trabajador lesionado del Fondo estatal para notificarle a L&I de un cambio de dirección.  Todos lo cambios de dirección deben someterse por escrito y estar firmados por el trabajador lesionado.



Formulario
F242-388-999

Otro(s) idioma(s):
Inglés
 
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
 
Solicitud para beneficios de pensión presentado por el cónyuge o los hijos

Formulario:  Usado por el cónyuge o dependiente elegido por el trabajador fallecido para recibir un beneficio de sobreviviente.  En el momento en que se determinó que el trabajador estaba permanentemenre y totalmente discapacitado el/ella tomó la decisión de dejar el beneficio de sobreviente al cónyuge o dependiente si el trabajador fallecía.



Formulario
F242-391-999

Otro(s) idioma(s):
Inglés
 
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
 
Declaración firmada para compensación de tiempo perdido

Para ser completada por los trabajadores lesionados que reclaman que tenian derecho a recibir el pago de beneficios de tiempo perdido no pagados anteriormente por un periodo que excede seis meses o $25,000.  Los trabajadores lesionados que soliciten beneficios por el tiempo perdido de trabajo actual debido a una lesión relacionada con el trabajo deben usar el Formulario de verificación de empleo, F242-052-999.



Formulario
F242-395-999

Otro(s) idioma(s):
Inglés
 
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
 
Se ha lesionado en el trabajo?

Tarjeta para billetera:  Explica cómo presentar un reclamo de compensación para los trabajadores por teléfono.



Publicación
F242-404-999
 
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
 
Tres cosas que debe conocer sobre la Red de proveedores médicos de L&I

Volante: Le explica a los trabajadores la información básica sobre la Red de proveedores médicos de L&I. Los trabajadores cubiertos por L&I y por las empresas autoaseguradas pueden utilizar el volante.  Se aplica a los trabajadores en el estado de Washington.  Incluye información para comunicarse por la Internet y el número de teléfono.  



Publicación
F242-406-999

Otro(s) idioma(s):
Inglés
 
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
 
Autorization del trabajador para obtener registros de trabajos despachados por el sindicato

Autorización del trabajador para obtener registros de trabajos despachados por el sindicato.



Formulario
F242-410-999

Otro(s) idioma(s):
Inglés
 
Hearing Aid Replacement Form

This form is used to request replacement hearing aids only.



Formulario
F242-414-000
 
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
 
Permanezca en el Trabajo: Una solución factible -- un programa para ayudar a los empleadores a mantener a los trabajadores lesionados en el trabajo -- paga la mitad del salario base además de otros gastos

Folleto: Proporciona un resumen del programa Permanezca en el Trabajo, un programa con un incentivo económico que anima a los empleadores del estado de Washington a encontrar trabajos livianos o de transición para trabajadores que se están recuperando de lesiones ocurridas en el trabajo. Incluye información sobre los requisitos que deben reunir, cómo hacer una solicitud y donde pueden obtener más información.



Publicación
F243-006-999

Otro(s) idioma(s):
Inglés
 
Performance Based Physical Capacities Evaluation

Used by occupational and physical therapy providers as an optional reporting format for a Performance-based Physical Capacities Evaluation.



Formulario
F245-023-000
 
Declaración de servicios de capacitación y modificación de trabajo

Formulario:  Para ser completado por los proveedores que facturan al Departamento por capacitación y servicios de modificación de trabajo.



Formulario
F245-030-999

Otro(s) idioma(s):
Inglés
 
REFUND NOTIFICATION Refunding Money to L&I to correct your account?

Used to Refund Money to L&I to correct your account REFUND NOTIFICATION



Formulario
F245-043-000
 
Provider Account Application - Independent Medical Examiner (IME)

In order to do independent medical exams a provider must obtain a provider account number with L&I. This packet includes the application and agreement with instructions, IME Provider Exam sites form (F245-047-000) and Request for Taxpayer ID and Certification - Form W-9 (F248-036-000) (10 pages). If you have questions, please email balk235@lni.wa.gov or call 360-902-6815.



Formulario
F245-046-000
 
Independent Medical Examination (IME) Provider Exam Sites

List the locations where the doctor does independent medical exams on a regular basis.



Formulario
F245-047-000
 
Approved Independent Medical Examiner (IME) Update

This document is used to update or correct an IME's contact, availability, qualifications and/or exam sites information.



Formulario
F245-051-000
 
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
 
Comentarios Sobre el Exámen Médico Independente

Usado por el trabajador lesionado para proporcionarle comentarios a L&I sobre su examen médico reciente de un Examen Médico Independiente (IME, por su sigla en inglés).



Formulario
F245-053-999

Otro(s) idioma(s):
Inglés
 
Submission of Provider Credentials for Interpretive Services

Used to apply as a interpretive service provider and to show what language(s) you hold credentials for. F248-011-000 Provider Application and Notice is added to this form.



Formulario
F245-055-000
 
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
 
Independent Medical Exam Template

Template used by a doctor during an independent medical exam.



Formulario
F245-058-000
 
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
 
Declaración para servicios misceláneos

Formulario:  Es utilizado por proveedores y trabajadores lesionados para cobrarle al Departamento por servicios tales como, cuidado dental; lentes; cuidado de enfermería en el hogar; equipo médico, servicios de intérprete; servicios que los trabajadores pagan por su cuenta y otros servicios.



Formulario
F245-072-999

Otro(s) idioma(s):
Inglés
 
CMS 1500 (formerly L&I Health Insurance Claim form)

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
 
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
 
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
 
Labor and Industries Prosthetic Device Request Form

Labor and Industries Prosthetic Device Request



Formulario
F245-340-000
 
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
 
Modificacion en el trabajo solicitud de asistencia

Para ser utilizado por un consejero vocacional, empleador, etc. para solicitar modificación de empleo para el trabajador lesionado.  Esto puede incluir herramientas y equipo comprado por L&I.  



Formulario
F245-346-999

Otro(s) idioma(s):
Inglés
 
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
 
Adaptación previa al trabajo solicitudad de ayuda

Formulario:  Este formulario puede utilizarlo un terapeuta o proveedor vocacional para solicitar una modificación de empleo para un trabajador lesionado antes de que el trabajador lesionado sea empleado, posiblemente en un programa de capacitación.  Esto puede incluir herramientas y equipo comprado por L&I.





Formulario
F245-350-999

Otro(s) idioma(s):
Inglés
 
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
 
Acuerdo de propiedad de herramientas y equipo para el plan de formacion profesional

Formulario: El trabajador lesionado está de acuerdo con los términos de propiedad de las herramientas y/o el equipo comprado como parte de su plan de capacitación de L&I.



Formulario
F245-351-999

Otro(s) idioma(s):
Inglés
 
Provider Credentialing Change Form

Providers use this form to notify L&I of a change of their business address, billing address and account termination. Also has info on how to notify L&I on a tax ID (EIN) number change, tax ID address change and/or name change.



Formulario
F245-365-000
 
Training Plan Cost Encumbrance

To record the training costs. For use only with plans approved after 1/1/2008.



Formulario
F245-374-000
 
Plan Time Encumbrance
To record the work plan time. For use only with plans approved after 1/1/2008.

Formulario
F245-376-000
 
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
 
Notice of Independent Medical Exam No-Show or Late Cancellation

Notice of Independent Medical Exam No-Show or Late Cancellation



Formulario
F245-382-000
 
Independent Medical Examination Fax Cover Sheet

Independent Medical Examination Fax Cover Sheet



Formulario
F245-383-000
 
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
 
L&I Chiropractic Consultant Application

This application is for doctors applying for second opinion examiner (consultant) status. Current consultants do not need to reapply.



Formulario
F245-393-000
 
Washington Practitioner Application

Washington Practitioner Application is used by providers applying for the L&I Provider Network.



Formulario
F245-411-000
 
Servicios de intérprete para trabajadores lesionados y víctimas de crimen

Volante: Describe los servicios de intérprete disponible a los trabajadores lesionados y a las víctimas de crimen.  Incluye información de cómo obtener un intérprete; quién puede interpretar y recibir pago; y el concepto básico de conducta profesional del intérprete.



Publicación
F245-412-999

Otro(s) idioma(s):
Inglés
 
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
 
Modificacion en la vivienda Reconocimiento de responsabilidades

Utilizada tanto como por los trabajadores y contratistas de licitación para leer, firmar y someter a L&I para verificar que han leído, entendido y aceptado sus responsabilidades respectivas en el proceso de modificación de viviendas



Formulario
F247-003-999

Otro(s) idioma(s):
Inglés
 
Non-Network Provider Application

Includes the F248-036-000 Statewide Payee Registration and W-9 form. For providers to complete that do not want to become a Labor and Industries network provider, or for a specialty that L&I is not accepting network applications for at this time. If you are applying to be a Labor and Industries network provider, please complete application process at www.ProviderNetwork.Lni.wa.gov



Formulario
F248-011-000
 
Electronic Billing Authorization

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



Formulario
F248-031-000
 
Hotline Tips for Medical Services Providers
Fact sheet: Provides tips to help medical service providers quickly obtain answers to claims and billing questions. Introduces L&I's Provider Hotline, Interactive Voice Response Message System and online Claim & Account Center.

Publicación
F248-040-000
 
Occupational or Physical Therapy Treatment Authorization Fax Request

Used by a therapy provider/clinic to request authorization for outpatient occupational or physical therapy services for L&I claims.



Formulario
F248-055-000
 
General Provider Billing Manual

General billing information for those providers that bill the department.



Manual
F248-100-000
 
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
 
Power of Attorney for Electronic Remittance Advice

Providers complete this form to authorize a clearinghouse or third party to receive the EDI 835 Electronic Remittance Advice file from L&I's Provider Express Billing (PEB).



Formulario
F248-355-000
 
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
 
Solicitud de cuenta para proveedores fuera del país

Esta solicitud es para proveedores de salud fuera de los Estados Unidos.  Los proveedores que brindan tratamiento a los trabajadores lesionados deben tener un número de proveedor para poder cobrarle al Departamento.



Formulario
F248-361-999

Otro(s) idioma(s):
Inglés
 
Medical Payment Guidance

Flyer: Describes how a payment for health-care services is mailed separately from the explanation for the payment (the remittance advice). An illustration explains how to link a payment with its explanation. Also includes information about how providers can always find their remittance advices online through L&I's Provider Express Billing.



Publicación
F248-366-000
 
¿Lesionado por un tercero? Usted tiene opciones legales

Folleto: Un resumen de los derechos legales y opciones que tiene un trabajador lesionado si una acción contra un tercero está relacionada con su reclamo de compensación para los trabajadores. Incluye el Formulario de elección contra terceros que debe ser completado por el trabajador. Aviso:  El formulario debe imprimirse, firmarse y enviarse por correo.

 



Formulario
F249-008-999

Otro(s) idioma(s):
Inglés
 
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
 
Supplemental Agreement Third Party Pharmacy Provider

This agreement is to define access, performance and legal requirements for third party pharmacy billers who submit bills to and receive payment from L&I on behalf of pharmacy providers. This agreement authorizes L&I to accept and remit monies due the Pharmacy using a third party pharmacy biller.



Formulario
F249-021-000
 
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
 
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
 
Doctor's Worksheet for Rating Dorso-Lumbar & Lumbo-Sacral Impairment

This worksheet is to help the attending physician perform impairment rating on their patients with permanent partial disability of the Dorso-Lumbar or Lumbo-Sacral spine.



Formulario
F252-006-000
 
Hearing Impairment Calculation Worksheet

Used by the attending doctor to determine hearing loss.



Formulario
F252-007-000
 
Medical Device Review Request

This form is so L&I's Office of the Medical Director can evaluate medical device(s) that the attending physican wants to use to treat an injured worker.



Formulario
F252-013-000
 
Individual Vocational Provider Account Change Form

To change an individual's (service provider's) name, add or delete referral categories, update certifications, leaving a firm, intern supervisor changes, and/or adding or deleting a branch for referrals.



Formulario
F252-021-000
 
Firm Vocational Provider Account Change

To change a firm's (payee provider's) branch address within the same service location, contact info, tax info, adding or deleting designee for your firm.



Formulario
F252-022-000
 
Vocational Closing Report Routing Sheet

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



Formulario
F252-027-000
 
Vocational Services Closing Cover Sheet

Used to close vocational services of an injured worker. This form is attached to Vocational Closing Report Routing Sheets F280-013-000, F280-014-000 or F252-027-000.



Formulario
F252-028-000
 
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
 
Intern Supplemental Application

Intern Supplemental Application



Formulario
F252-030-000
 
Sample Self-Employment Agreement

Sample of a letter a return to work person would use to assist L&I in determining whether services or funds should be authorized to assist them in becoming self-employed.



Formulario
F252-032-000
 
Employer's Job Description

Used by employer of record to prepare a written job description for a light-duty job, transitional, modified duty job, or alternative job when an injured worker is unable to work due to an industrial injury or occupational disease. The form includes a description of the job tasks, machinery, tools, equipment and personal protective equipment used, and the physical demands of the job. After completing the employer's job description form, the employer gives it to the injured worker's doctor for review and approval.



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

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



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

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



Formulario
F252-052-000
 
Doctor's Worksheet for Rating Cervical and Cervico-Dorsal Impairment

Doctor's Worksheet for Rating Cervical and Cervico-Dorsal Impairment



Formulario
F252-056-000
 
Modificaciones de la vivienda para trabajadores con lesiones catastróficas

Hoja de información: Respuestas sobre el beneficio de la modificación de la vivienda del programa de compensación para los trabajadores del estado de Washington, quienes califican, lo que puede pagar L&I y donde obtener más información.



Publicación
F252-060-999

Otro(s) idioma(s):
Inglés
 
Modificaciones de la vivienda para trabajadores con lesiones catastróficas – Preguntas y respuestas para contratistas

Hoja de información: Respuestas sobre el beneficio de la modificación de la vivienda del programa de compensación para los trabajadores del estado de Washington y el proceso de licitación para los contratistas interesados en el trabajo.



Publicación
F252-061-999

Otro(s) idioma(s):
Inglés
 
Job Analysis

Used by vocational rehabilitation counselors (VRCs) to document the physical demands of jobs.



Formulario
F252-072-000
 
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
 
Cómo hacer la mejor elección de tratamiento para el dolor crónico en la parte inferior de su espalda

Hoja de información:  Revisa las opciones que un trabajador lesionado con dolor en la parte inferior de la espalda debe considerar para determinar la elección del mejor tratamiento.



Publicación
F252-081-999

Otro(s) idioma(s):
Inglés
 
Provider Application and Notice for new firms

Complete this application and the StateWide Payee W-9 if you are applying for a firm Provider Number with L&I.



Formulario
F252-088-000
 
L&I Benefits for Workers Who Are Terminally Ill

Answers questions persons with a terminal illness may ask about benefits from L&I.



Publicación
F252-094-000
 
Convenio para el tratamiento con opioides

Utilice este convenio de tratamiento al iniciar la terapia con opioides para controlar el dolor crónico.  El convenio debe ser renovado cada año o cuando hay un proveedor nuevo proporcionándole recetas.



Formulario
F252-095-999

Otro(s) idioma(s):
Inglés
 
Job Analysis Summary

Summary that goes on top of a job analysis.  Gives the physician a snapshot of the physical demands of a job.



Formulario
F252-101-000
 
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
 
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
 
Queja por suprimir un reclamo

Un trabajador lesionado puede someter  este formulario si su empleador ha suprimido su derecho a presentar un reclamo por una lesión.



Formulario
F262-024-999

Otro(s) idioma(s):
Inglés
 
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
 
Targeting Fraud and Abuse in Washington State's Workers' Compensation Program: 2009 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 for fiscal year 2009.

Publicación
F262-034-000
 
Stop Work Payroll Report

Stop Work Payroll Report



Formulario
F262-043-000
 
Targeting Fraud and Abuse in Washington State's Workers' Compensation Program: 2010 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 for fiscal year 2010.

Publicación
F262-044-000
 
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
 
Las primas de compensación para trabajadores no pagadas por su subcontratista podrían ser su responsabilidad

Hoja de información: Le informa a los contratistas de construcción cómo protegerse de la responsabilidad por las primas de compensación para los trabajadores no pagadas por su subcontratista.



Publicación
F262-262-999

Otro(s) idioma(s):
Inglés
 
Targeting Fraud and Abuse in Washington State's Workers Compensation Program: 2006 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
F262-276-000
 
Targeting Fraud and Abuse in Washington State's Workers' Compensation Program: 2007 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
F262-280-000
 
Plan Development Quality Assurance Review Form

For use internally by L&I Vocational Service Specialists (VSSs) to determine if all required components are included in the submitted plan. Can be used by VRCs as a tool. DO NOT SUBMIT TO L&I.



Formulario
F280-007-000
 
Assessment Eligible Quality Assurance Review Form

For use internally by L&I Vocational Service Specialists (VSSs) to determine if all required components are included in the submitted assessment.  Can be used by VRCs as a tool.  DO NOT SUBMIT TO L&I.



Formulario
F280-008-000
 
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
 
Accountability Agreement

This document provides the facts necessary to make an informed decision regarding vocational retraining benefits and explains the responsibilities you and your vocational counselor (VRC) have. For OJT retraining plans, please refer to form F280-029-000.



Formulario
F280-016-000

Otro(s) idioma(s):
Español
 
Acuerdo de responsabilidad

Formulario: Este documento proporciona los datos necesarios para tomar una decisión informada con referencia a los beneficios de capacitación vocacional y explica las responsabilidades que usted y su consejero vocacional (VRC, por su sigla en inglés) tienen.



Formulario
F280-016-999

Otro(s) idioma(s):
Inglés
 
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
 
Evaluando su capacidad para trabajar: sus derechos y responsabilidades, servicios de rehabilitación vocacional

Folleto: Explica lo básico de la etapa de evaluación de los servicios vocacionales para los trabajadores lesionados. L&I le envia este folleto a los trabajadores lesionados cuando son referidos para servicios de evaluación.



Publicación
F280-017-999

Otro(s) idioma(s):
Inglés
 
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
 
Plan de desarrollo: ¿Cuáles son mis derechos y responsabilidades? Servicios de rehabilitación vocacional

Folleto: Explica lo básico de la etapa del plan de desarrollo de servicios vocacionales para trabajadores lesionados.  L&I envia este folleto a los trabajadores lesionados cuando son referidos para servicios del plan de desarrollo.  Se requiere que el consejero de rehabilitación vocacional asignado revise este folleto con el trabajador durante la reunión inicial en persona. 



Publicación
F280-018-999

Otro(s) idioma(s):
Inglés
 
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
 
Llevando a cabo su plan vocacional: sus derechos y responsabilidades durante el plan de implementación, Servicios de rehabilitación vocacional

Folleto: Explica lo básico de la etapa del plan de implementación de servicios vocacionales para trabajadores lesionados. L&I envia este folleto a los trabajadores lesionados cuando son referidos para servicios del plan de desarrollo. Se requiere que el consejero de rehabilitación vocacional asignado revise este folleto con el trabajador durante la reunión inicial en persona. 



Publicación
F280-019-999

Otro(s) idioma(s):
Inglés
 
Programa con Incentivos para Volver a Emplear a Trabajadores Lesionados

Folleto:  Describe el Programa con Incentivos para Volver a Emplear 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
 
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
 
Acuerdo de responsabilidad de la capacitación durante el transcurso del trabajo

Formulario: Acuerdo de responsabilidad de la capacitación durante el transcurso del trabajo en español.



Formulario
F280-029-999

Otro(s) idioma(s):
Inglés
 
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
 
Option 2: What You Need to Know, Vocational Rehabilitation Services
Booklet: Explains what happens when an individual selects "Option 2" and choose not to participate in the approved training plan.

Publicación
F280-036-000
 
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
 
Cuestionario Vocacional/Historia de trabajo

Cuestionario vocacional/historia de trabajo para uso de los proveedores vocacionales que sirven a los trabajadores lesionados.



Formulario
F280-038-999
 
On-The-Job Training (OJT) Agreement for Vocational Providers

On-The-Job Training (OJT) Agreement for Vocational Providers



Formulario
F280-039-000
 
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
 
Vocational Technical Stakeholder Group (VTSG) Application

This form is for recruiting private sector vocational counselors to be on the Vocational Technical Stakeholder Group (VTSG). The form is made available on the department’s vocational website when recruiting for new members to assist the department in addressing vocational issues and formulating policy. Prospective applicants are expected to download, sign, and return the form to PSRS for consideration.



Formulario
F280-049-000
 
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
 
Preguntas frecuentes sobre el beneficio del Programa de Incentivos para Volver a Emplear Trabajadores Lesionados

Hoja de información: Incluye información relacionada con los beneficios de la certificación de beneficios del Programa de Incentivos para Volver a Emplear Trabajadores Lesionados, respuestas a preguntas frecuentes de los trabajadores, información de teléfonos y del sitio Web.



Publicación
F280-052-999

Otro(s) idioma(s):
Inglés
 
Application for Asbestos Contractor Certification

Contractors use this form to apply to be a certified asbestos contractor in Washington state.



Formulario
F413-007-000
 

Employer’s Guide to the Hazard Communication Rule  

Booklet: Washington State's new Hazard Communication rule became effective April 15, 2013. It is intended to improve understanding of hazard information found on product labels. The booklet includes training requirements, a Q&A about who is covered, pictograms, descriptions of hazards and everything employers need to know and do to be in compliance.

The changes are based on the International Globally Harmonized System of Classification and Labeling of Chemicals (GHS).



Publicación
F413-012-000

Otro(s) idioma(s):
中国的
한국의
Español
Việt
 
Guide to the Hazard Communication Rule (Vietnamese)

Booklet: Washington State's new Hazard Communication rule became effective April 15, 2013. It is intended to improve understanding of hazard information found on product labels. The booklet includes training requirements, a Q&A about who is covered, pictograms, descriptions of hazards and everything employers need to know and do to be in compliance.

The changes are based on the International Globally Harmonized System of Classification and Labeling of Chemicals (GHS).



Publicación
F413-012-555

Otro(s) idioma(s):
中国的
Inglés
한국의
Español
 
Employer's Guide to the Hazard Communication Rule (Korean)

Booklet: Washington State's new Hazard Communication rule became effective April 15, 2013. It is intended to improve understanding of hazard information found on product labels. The booklet includes training requirements, a Q&A about who is covered, pictograms, descriptions of hazards and everything employers need to know and do to be in compliance.

The changes are based on the International Globally Harmonized System of Classification and Labeling of Chemicals (GHS).



Publicación
F413-012-777

Otro(s) idioma(s):
中国的
Inglés
Español
Việt
 
Employer's Guide to the Hazard Communication Rule (Chinese)

Booklet: Washington State's new Hazard Communication rule became effective April 15, 2013. It is intended to improve understanding of hazard information found on product labels. The booklet includes training requirements, a Q&A about who is covered, pictograms, descriptions of hazards and everything employers need to know and do to be in compliance.

The changes are based on the International Globally Harmonized System of Classification and Labeling of Chemicals (GHS).



Publicación
F413-012-888

Otro(s) idioma(s):
Inglés
한국의
Español
Việt
 
Guía sobre la norma de comunicación de riesgos químicos

Folleto:  La norma de comunicación sobre los riesgos químicos se hizo efectiva el 15 de abril de 2013.  Se intenta mejorar el entendimiento de la información de peligro que se encuentra en las etiquetas de los productos.  El folleto incluye los requisitos de capacitación, preguntas y respuestas sobre quien está cubierto, pictogramas, descripciones de los peligros y todo lo que los empleadores necesitan saber y hacer para poder cumplir con la norma.

Los cambios están basados en el Sistema globalmente armonizado de clasificación y etiquetado de productos químicos (GHS, por su sigla en inglés).

 Esta publicación por el momento no está disponible debido a que hay revisiones en progreso.



Publicación
F413-012-999

Otro(s) idioma(s):
中国的
Inglés
한국의
Việt
 
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
 
Your Body, Your Job: Preventing Carpal Tunnel Syndrome and Other Upper Extremity Musculoskeletal Disorders
Pamphlet/booklet: Reviews the symptoms and risk factors for carpal tunnel syndrome and several other musculoskeletal disorders that affect the shoulder, arm and elbow. Discusses prevention approaches and where to get more information.

Publicación
F413-024-000

Otro(s) idioma(s):
Español
 
Su cuerpo, su empleo: prevención del síndrome del túnel carpiano y otros trastornos músculo esqueléticos de las extremidades superiores

Folleto:  Indica los síntomas y factores de riesgo para el síndrome del túnel carpiano y otros transtornos músculo esqueléticos que afectan el hombro, brazo y codo.  Discute los enfoques de prevención y dónde pueden encontrar más información.  



Publicación
F413-024-999

Otro(s) idioma(s):
Inglés
 
Asbestos Abatement Project Notice of Intent and L&I DOSH Asbestos Program

Notice is not required for any asbestos project involving less than forty-eight (48) square feet of surface area, or less than ten (10) linear feet of pipe unless the surface area of the pipe is greater than forty-eight (48) square feet. Get instructions to complete the form.



Formulario
F413-025-000
 
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
 
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
 
Your Lungs, Your Work, Your Life: What You Should Know about Work-related Asthma

Pamphlet/booklet: Briefly reviews the symptoms and causes of work-related asthma and explains prevention and treatment approaches.



Publicación
F413-060-000

Otro(s) idioma(s):
русский
Español
 
Your Lungs, Your Work, Your Life: What You Should Know about Work-related Asthma (Russian)
Pamphlet/booklet: Briefly reviews the symptoms and causes of work-related asthma and explains prevention and treatment approaches.

Publicación
F413-060-444

Otro(s) idioma(s):
Inglés
Español
 
Sus pulmones su trabajo su vida: lo que debería saber acerca del asma ocupacional

Folleto:  Brevemente indica los síntomas y las causas del asma relacionada con el trabajo  y explica  la prevención y enfoques de tratamiento.



Publicación
F413-060-999

Otro(s) idioma(s):
Inglés
русский
 
Cholinesterase Monitoring Reimbursement Request

Employers use this form to request reimbursement for the reasonable costs of training, travel, recordkeeping, and medical expenses for Cholinesterase Monitoring.



Formulario
F413-062-000
 
Cholinesterase Blood Testing Choice

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



Formulario
F413-064-000

Otro(s) idioma(s):
Español
Español
 
Elección para prueba de sangre de colinesterasa

Formulario:  Es utilizado para indicar si usted elije o no que se le hagan examenes de colinesterasa en la sangre.



Formulario
F413-064-999

Otro(s) idioma(s):
Inglés
Inglés
 
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
 
Cholinesterase Monitoring Health Care Provider Recommendations

Filled out by the provider. This form gives the recommendations by the provider of what needs to be done based on the test results on the employee.



Formulario
F413-070-000

Otro(s) idioma(s):
Español
Español
 
Monitoreo de la colinesterasa - recomendaciones del proveedor médico (ejemplo)

El proveedor llena este formulario.  Este formulario da recomendaciones por parte del proveedor sobre lo que necesita hacerse basado en los resultados de las pruebas hechas al empleado.



Formulario
F413-070-999

Otro(s) idioma(s):
Inglés
Inglés
 
Safety Standards for WAC 296-78- Sawmillis & Woodworking Operations

The Department of Labor and Industries has rewritten and reorganized for clarity and ease of use, Chapter 296-78 WAC, Sawmills and Woodworking Operations.



Manual
F414-010-000
 
Safety Standards for Laundry Machinery and Operations WAC 296-303

Laundry Machinery and Operations applies to moving parts of equipment used in laundries and to conditions peculiar to this industry, with special reference to the point of operation of laundry machines in an establishment wherein the washing, ironing, or other finishing of clothes, or any other textiles is done.



Manual
F414-012-000
 
Safety Standards for Logging Operations WAC 296-54

This chapter establishes safety practices for all types of logging, log road construction and other forest activities using logging machinery and/or power saws regardless of the end use of the wood. This includes; logging, cutting and transporting timber, cutting timber, log harvesting logging, pulpwood logging camps, rails, rough wood, manufacturing, stump removing in the field, timber piling, timber pole cutting, tree chipping in the field, wood chipping in the field. In addition, logging and personal protective equipment, hand and portable powered tools, falling and bucking, tree pulling, mechanized falling, climbing equipment, rigging, spars, wire rope and various types of cable logging systems, guylines, tail/lift trees and anchors, yarding, skidding, landing, transportation of logs and stationary trailer loaders, log unloading, booms, and rafting grounds, transportation crews, signals and signal systems.



Manual
F414-016-000
 
Safety Standards for WAC 296-32, Telecommunications

Rules for employees working with telecommunication systems



Manual
F414-017-000
 
Variance Application - IND S&H

Use this form to apply for a variance for an allowed deviation from a specific safety or health standard when an employer substitutes measures which afford an equal degree of safety.



Formulario
F414-021-000
 
Safety Standards for Shipbuilding, Ship Repairing and Shipbreaking Chapter 296-304 WAC

Safety Standards for Shipbuilding, Ship Repairing and Shipbreaking Chapter 296-304 WAC



Manual
F414-025-000
 
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 Standards for WAC 296-56 - Longshore, Stevedore and Waterfront Related Operations

The rules included in this chapter apply to any and all waterfront operations for longshore, stevedore and waterfront  related operations, cargo handling, and related terminal operations and equipment under the jurisdiction of the  Department of  Labor and  Industries.



Manual
F414-034-000
 
Administrative Rules - Chapter 296-27, 350 & 360 WAC & RCW 49.17

These WAC and RCW rules explain the record keepkeeping responsibilities of businesses such as medical providers, employers who handle biohazards, etc.



Manual
F414-037-000
 
Safety Standards for Possession, Handling, and Use of Explosives WAC 296-52

Explosives mean any chemical compound or mechanical mixture commonly intended or used for the purpose of producing an explosion.



Manual
F414-038-000
 
Commercial Diving Operations, Chapter 296-37 WAC

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



Manual
F414-039-000
 
Safety Standards for WAC 296-24 - General Safety and Health

The rules in this chapter are designed to protect the safety and health of employees by creating a healthy work environment by establishing requirements to control safety hazards in the workplace.



Manual
F414-040-000
 
Safety Standards for WAC 296-62, General Occup Health

The rules in this chapter are designed to protect the health of employees and help to create a healthy workplace by establishing requirements to control health hazards. Requirements for chemical hazard communication programs, workplace lighting levels and exposure records are in chapter 296-800 WAC, the safety and health core rules.



Manual
F414-042-000
 
Safety Standards for WAC 296-59, Ski Area Facilities & Operations

Rules for ski areas



Manual
F414-048-000
 
Safety Standards for Core Rules WAC 296-800

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



Manual
F414-059-000
 
WISHA Occupational Exposure to Bloodborne Pathogens - Chapter 296-823 WAC

Pathogenic microorganisms that are present in human blood and can cause disease in humans.



Manual
F414-073-000
 
Workplace Safety and Health Rules and Guides

This CD has been discontinued, but the safety and health rules and guides are available on the L&I website.

For more information, see the links in the "Websites" section below.

These links contain all workplace safety and health rules for Washington State and policies and related laws. Included are guides covering accident prevention programs (APP) and personal protective equipment (PPE).

 



CD
F414-074-034
 
Chapter 296-807 WAC - Portable Power Tools

Portable power tools applies to hand-held power tools; circular saws, belt sanding machines, compressed air powered tools, powder actuated fastening systems designed to use the expanding gases from a powder load to propel a stud, pin, fastener, or other object into hard structural material, consumer and commercial power lawnmowers, portable hand- or power-operated hydraulic, mechanical ratchet and mechanical screw jacks.



Manual
F414-089-000
 
Safety Standards for WAC 296-67 - Process Safety Management of Highly Hazardous Chemicals

The purpose this of section, Chapter 296-67 WAC, Process safety management of highly hazardous chemicals, contains requirements for preventing or minimizing the consequences of catastrophic releases of toxic, reactive, flammable, or explosive chemicals. These releases may result in toxic, fire, or explosion hazards.



Manual
F414-090-000
 
Safety Standards for WAC 296-832, Late Night Retail

Crime protection requirements for a retail establishment operating between 11pm and 6am. (Does not include restaurants, hotels, taverns, or any lodging facilities)



Manual
F414-112-000
 
Safety Standards for Railroad Clearances and Walkways in Private Rail Yards and Plants WAC 296-860

This chapter applies to all railroad clearances and walkways in rail yards and plants including logging railroad yards such as mill yards, maintenance yards and sorting yards.

To prevent injuries and fatalities to employees by maintaining safe railroad clearances and walkways in your rail yards and plants.



Manual
F414-113-000
 
Safety Standards for WAC 296-878, Window Cleaning

Safe window cleaning requirements.



Manual
F414-114-000
 
Safety Standards for WAC 296-829, Helicopters Used as Lifting Machines

Chapter 296-829 WAC applies to helicopters when used to carry loads, suspended with a cargo sling, powered hoist, or other attaching methods.



Manual
F414-121-000
 
Safety Standards for WAC 296-802, Employee Medical and Exposure Record

The purpose of this chapter is to provide employees and their designated representatives the right to access relevant medical and exposure records. It also describes the procedures WISHA will follow when accessing confidential medical information.



Manual
F414-122-000
 
Safety Standards Lockout/Tagout WAC 296-803

Lockout/Tagout applies to the service and maintenance of machines and equipment, including piping systems, if employees could be injured by the unexpected energization or start up of the machine or equipment or release of stored energy. Energy sources include mechanical, hydraulic, pneumatic, chemical, thermal, or other energy, including gravity. Machines and equipment include those that produce high intensity electromagnetic fields.



Manual
F414-124-000
 
Safety Standards for Forklifts and Other Powered Industrial Trucks WAC 296-863

This chapter applies to powered industrial trucks, electric motors or internal combustion engines, fork trucks, forklifts, tractors, platform lift trucks, motorized hand trucks and other specialized industrial trucks.



Manual
F414-126-000
 
Safety Standsards for WAC 296-874 - Scaffolds

Scaffolds, Chapter 296-874 WAC, applies to suspended and supported scaffolds, including their supporting structure and anchorage points. A scaffold is a temporary elevated platform, including its supporting structure and anchorage points, used for supporting employees or materials. A suspended scaffold is one or more platforms suspended from an overhead structure by ropes or other non-rigid means.



Manual
F414-128-000
 
Safety Standards for Ethylene Oxide WAC 296-855

Ethylene Oxide is a flammable colorless gas that is commonly used to sterilize medical equipment and as a fumigant for certain agricultural products. It is also used as an intermediary in the production of various chemicals such as ethylene glycol, automotive antifreeze, and polyethylene. Exposure is the contact an employee has with ethylene oxide, whether or not protection is provided by respirators or other personal protective equipment (PPE). Exposure can occur through various routes of entry such as inhalation, ingestion, skin contact, or skin absorption.

 



Manual
F414-132-000
 
Safety Standards for Ladders, Portable and Fixed WAC 296-876

This chapter applies to portable and fixed ladders, including job-made wooden ladders, ladder safety, the proper construction, use, placement, and care in handling ladders.



Manual
F414-133-000
 
Safety Standards for Administrative Rules WAC 296-900

Administrative Rules and the DOSH Administrative Manual affords employers the right to administrative and judicial review of alleged violations, initial penalties and abatement periods.



Manual
F414-136-000
 
Safety Standards for WAC 296-856 Formaldehyde

Applies to all occupational exposure to formaldehyde. Formaldehyde includes formaldehyde gas, its solutions, and materials that release formaldehyde.



Manual
F414-143-000
 
The DOSH Consultation Manual

The DOSH Consultation Manual provides guidance regarding some of the internal operations of L&I and the Division of Occupational Safety and Health (DOSH). The contents of the manuals are not enforceable by any person or entity against the Department of Labor and Industries or the State of Washington.



Manual
F414-151-000
 
Fall Protection Basics for Construction Activities

Booklet: Provides an overview of revised fall protection rules and requirements for construction activities effective April 1, 2013.



Publicación
F414-154-000

Otro(s) idioma(s):
Español
 
Lo básico sobre la protección contra caídas en actividades de la industria de la construcción

Folleto:  Proporciona un resumen de las normas modificadas de protección contra caídas y de los requisitos para las actividades en la construcción con fecha de vigencia del 1º de abril de 2013.



Publicación
F414-154-999

Otro(s) idioma(s):
Inglés
 
Safety Standards for WAC 296-901 - Global Harmonized System for Hazard Communication

Chapter 296-901 WAC, GHS is the Globally Harmonized System of Classification and Labeling of Chemicals. The GHS is a system for standardizing and harmonizing the classification and labeling of chemicals.



Manual
F414-155-000
 
Safety and Health Discrimination Complaint

Use this form to file a complaint when you feel you've been discriminated against or discharged for reporting a workplace safety hazard.



Formulario
F416-011-000

Otro(s) idioma(s):
Español
 
Queja de discriminación de la División de Seguridad y Salud Ocupacional

Si Usted piensa que ha sido discriminado o despedido por reportar los peligros existentes en su lugar de trabajo, utilice este formulario para presentar una queja.



Formulario
F416-011-999

Otro(s) idioma(s):
Inglés
 
Application for Charter Boat Operators License

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



Formulario
F416-034-000
 
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
 
Mobile Cranes/Derricks Worksheet for Construction Industry

Mobile Cranes/Derricks Worksheet for Construction Industry



Formulario
F416-043-000
 
Cranes, Derricks and Material Handling Devices Worksheet for Maritime Industry

Use this form for the inspection of cranes, derricks and materials handling devices on waterfront operations



Formulario
F416-051-000
 
Bulk Cargo Spouts, Suckers, and Similar Equipment for Maritime Operations

Bulk Cargo Spouts, Suckers, and Similar Equipment for Maritime Operations



Formulario
F416-052-000
 
Physical Exam - Charter Boat Operators License

This form is used by applicants applying for a charter boat operators license to have completed by a physician for an operators license



Formulario
F416-056-000
 
Charter Vessel Inspection

Form used for the applicant to complete a Certification of Inspection of a charter boat.



Formulario
F416-058-000
 
Application for Accreditation Cranes/Derricks and other Material Handling Devices

Application to become an accredited crane certifier.



Formulario
F416-063-000
 
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
 
Application for Permit to Operate Radio System in Designated Area

This form is used by the logging industry to apply for a permit to operate a radio signal system. What you type in the top form appears in the bottom one, so you have a copy.



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

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



Publicación
F416-132-000

Otro(s) idioma(s):
Español
 
Una guía de seguridad y salud del lugar de trabajo en el estado de Washington

Folleto: Provee un resumen de la Ley de Seguridad y Salud Industrial de Washington (WISHA, por su sigla en inglés), derechos y responsabilidades del trabajador y del empleador, cumplimiento de las leyes de WISHA y los servicios de consultoría y educación que L&I proporciona. El título anterior era, Una guía de WISHA.



Publicación
F416-132-999

Otro(s) idioma(s):
Inglés
 
Overhead Crane Bridge, Monorail, Gantry Worksheet for Construction
Overhead Crane Bridge, Monorail, Gantry Worksheet for Construction.

Formulario
F416-141-000
 
Logging Emergency Medical Plan (Logging Safety and Health Meetings)

Use this two part form for employers to record work locations and emergency rescue info and for holding safety meetings for each new jobsite



Formulario
F417-014-000
 
Forklift Safety Guide
Book: Provides general information on kinds of forklifts, principles of physics that apply to forklifts, training requirements for forklift operators, basic operator safety rules, dangers of carbon monoxide, and safety while servicing a forklift.

Publicación
F417-031-000
 
Crew Leader Safety Meeting

Use this form to document the minutes of your safety meetings.



Formulario
F417-049-000
 
Quick Tips for Lifting/Consejos breves para levantar cargas (English/español)

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

Hoja de información:  Proporciona 10 consejos para levantar objetos con seguridad.  Contiene ilustraciones.

 



Publicación
F417-055-909
 
Actas de la reúnion de seguridad

Use este formulario para registrar las actas de sus reuniones de seguridad, estos registros deben mantenerse por un año a partir de la fecha de cada reunión.



Formulario
F417-087-999

Otro(s) idioma(s):
Inglés
 
Guidelines for Selecting Reserve Trees
Book: Provides technical guidance on retaining reserve trees in concert with safe work practices and forest and wildlife management goals. Produced cooperatively by state and federal agencies and industry groups.

Publicación
F417-092-000
 
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.



Checklist
F417-104-000
 
Lessons for Lifting & Moving Materials
Book: Identifies work areas, tasks and procedures that place employees at risk of injury. Describes and illustrates methods that help reduce the risk of injury.

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

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/español)

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
 
Forklift Safety: Training requirements and helpful tips

Fact sheet: Provides answers to the most-often asked questions about forklift training. Includes a checklist that employer may use to document that employees have been trained and/or evaluated in the required topics.



Publicación
F417-202-000
 
Borrower Agreement Form Safety and Health Video Library

Borrower Agreement Form - To open an account and borrow videos, please fill out this form.



Formulario
F417-205-000
 
Reservation Form Safety and Health Video Library

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



Formulario
F417-206-000
 
Personal Protective Equipment (PPE) Guide
Book: This guide helps employers comply with the WISHA Personal Protective Equipment rules. It covers general personal protective equipment and PPE requirements used to protect the head, eyes and face, hand and arm, foot and leg, and body (torso) in most work environments.

Publicación
F417-207-000
 
Fall Protection: Responding to Emergencies
Book: This guide is for employers and for employees who work from exposed, elevated surfaces. It covers the following: what to do to prevent fall-related emergencies and how to respond promptly if a fall-related emergency occurs. Includes illustrations of aided-rescue equipment systems.

Publicación
F417-208-000
 
Keep Your Employees Safe and Working

Pamphlet/booklet: Describes the benefits of free employer consultations offered by L&I's Division of Occupational Safety and Health (DOSH). These services include on-site safety and/or industrial hygiene consultations, ergonomics assistance and risk management advice.



Publicación
F417-209-000

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

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
 
A Safe and Healthy Workplace Begins with You
Pamphlet: Provides an overview of employers' responsibilities for workplace safety and health in Washington State. Covers free L&I services, including workplace consultations, online training and prevention resources and required posters. Intended for new businesses or businesses hiring employees for the first time.

Publicación
F417-210-000
 
Jorge's New Job: Cholinesterase Testing in Washington State / Un Nuevo Trabajo para Jorge(English/Spanish)

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

Panfleto/folleto:  Utiliza un formato de cuento con diálogo y fotografías para explicar los peligros de la colinesterasa, el programa de monitoreo del estado y la importancia del uso adecuado del equipo de seguridad cuando se trabaja con pesticidas.



Publicación
F417-213-909
 
Protect Yourself and Your Family from Lead Poisoning
Pamphlet/booklet: Explains the risks of lead exposure for workers who work on outdoor steel structures, and harmful effects on workers and their families. It includes a poster about the importance of safe work practices and procedures.

Publicación
F417-214-000
 
Heat-related Illness Education Card/ Tarjeta de educación sobre enfermedades relacionadas con el calor (English/español)

Identifies the effects of heat exhaustion and heat stroke on the body and what to do if you observe symptoms. Reviews prevention steps. PDF file is set up for two copies to print at one time.

Tarjeta: Identifica los efectos del agotamiento por el calor y la insolación en el cuerpo y lo que puede hacer si observa estos síntomas. Revisa los pasos para la prevención.  El archivo en PDF está configurado para que se impriman dos copias al mismo tiempo.



Publicación
F417-218-909
 
Voluntary Protection Program (VPP)
Fact sheet: Provides an overview of the VPP, a program that recognizes occupational safety and health excellence. Identifies benefits and includes testimonials from companies awarded VPP status.

Publicación
F417-221-000
 
Safety and Health Investment Projects (SHIP) Grant Program

Booklet: Introduces the SHIP Grant Program and application process. SHIP awards grants for innovative projects that (1) prevent workplace injuries, illnesses and deaths and (2) encourage injured workers to return to work early and reduce long-term disability.



Publicación
F417-224-000
 
Safety for Commercial Dive Teams
Fact sheet: Provides an overview of safety for commercial dive teams, summarizes the key requirements of commercial diving regulations (WAC 296-37), and includes contact information.

Publicación
F417-226-000
 
Safety and Health Program Assessment Worksheet

Safety and Health Program Assessment Worksheet



Formulario
F417-227-000
 
Nail Gun Safety: A Guide for Construction Contractors

Booklet: Gives information needed to prevent nail gun injuries for construction employers.



Publicación
F417-232-000
 
Ergonomics Consultation: Free, Confidential, Powerful Impact on Your Bottom Line

Pamphlet: Provides information to employers interested in a free ergonomics consultation for their business. Explains the importance of workplace ergonomics and how L&I can help to assess injury-causing tasks, and help develop an ergonomics program.



Publicación
F417-233-000
 
Tractor Safety: Rollover Protection and Seatbelts

Pamphlet: Summarizes the safety rules for rollover protective structures (ROPS) and seatbelts on tractors. Also lists exemptions and provides other information about safe operation of tractors.



Publicación
F417-234-000

Otro(s) idioma(s):
Español
 
Seguridad con los tractores: protección contra vuelcos y los cinturones de seguridad

Folleto: Resumen de las reglas de seguridad para la barra protectora contra vuelcos (ROPS, por su sigla en inglés) y los cinturones de seguridad en los tractores. También lista las exenciones y proporciona otra información sobre la operación segura de tractores.



Publicación
F417-234-999

Otro(s) idioma(s):
Inglés
 
Demounting and Mounting Procedures for Tubeless Truck and Bus Tires

Poster for tire and rim servicing. To be displayed with F417-237-000-B Demounting and Mounting Procedures for Tube-type Truck and Bus Tires and F417-237-000-C Multi-piece Rim Matching Chart. This poster must be printed at least 2'x3' in size.



Cartel
F417-237-000-A
 
Multi-piece Rim Matching Chart

Poster for tire and rim servicing. To be displayed with  F417-237-000-A Demounting and Mounting Procedures for Tubeless Truck and Bus Tires and F417-237-000-B Demounting and Mounting Procedures for Tube-type Truck and Bus Tires. This poster must be printed at least 2'x3' in size.



Cartel
F417-237-000-C
 
When a Loved One Dies at Work

Brochure: Provides information to loved ones of workers who died from a job-related injury or illness, including how to apply for survivor benefits. Explains the L&I fatality investigation and how family members can stay informed of the investigation's status.



Publicación
F417-240-000

Otro(s) idioma(s):
Español
 
Cuando un ser querido fallece en el lugar de trabajo

Folleto: Proporciona información para los seres queridos de trabajadores que mueren de una lesión o enfermedad relacionada con el trabajo, incluyendo cómo solicitar beneficios de sobreviviente. Explica la investigación de L&I por una muerte y cómo los miembros de la familia pueden mantenerse informados sobre el estado de la investigación.



Publicación
F417-240-999

Otro(s) idioma(s):
Inglés
 
Workplace Safety and Health Pocket Guide

Pocket guide: Provides links to online information, including safety and health consultations, how to develop a safety program, reporting hazards and injuries, other safety training, and information for teen workers.



Publicación
F417-241-000
 
Preguntas y Respuestas:Comunicación sobre los riesgos químicos

Hoja de información: Proporciona información sobre cambios a los reglamentos federales de comunicación de la Administración de Seguridad y Salud Ocupacional (OSHA, por su sigla en inglés), los cuales causan la necesidad para cambios en la norma del estado de Washington.  Se proyecta que los cambios mejoren el entendimiento de la información de peligro que se encuentra en las etiquetas de los productos para prevenir más efectivamente las lesiones, enfermedades y muertes.



Publicación
F417-242-999

Otro(s) idioma(s):
Inglés
 
Safety and Health Discrimination in the Workplace

Brochure: Employees have the right to report concerns about safety and health in their workplace. This brochure 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.



Publicación
F417-244-000

Otro(s) idioma(s):
Español
 
Discriminación de seguridad y salud en el lugar de trabajo

Folleto: Los empleados tienen derecho a reportar sus inquietudes sobre seguridad y salud en sus lugares de trabajo.  Este folleto describe las “actividades protegidas": bajo la Ley de Seguridad y Salud Industrial de Washington (WISHA, por su sigla en inglés) y explica lo que debe hacer un empleado si él/ella es castigado o despedido por ejercer estos derechos.



Publicación
F417-244-999

Otro(s) idioma(s):
Inglés
 
Q&A: Cranes, Rigging and Personnel Lifting Rule, Chapter 296-155 WAC, Part L

Q&A Factsheet: Answers to questions crane or derrik operators/owners might have regarding vehicle/operator certification and training required for cranes and derriks based on possible construction site scenerios.



Publicación
F417-245-000
 
Risk Management Consultation

Pamphlet/booklet: Describes the benefits of free risk management consultations. L&I’s Risk Managers can provide: data and analysis specific to your business that shows how claims can affect the premiums you pay; show you the cost/benefit of claim management strategies; identify return-to-work options and resources; and review best practices in hiring strategies and procedures.



Publicación
F417-246-000
 
2014 Workplace Safety and Health Calendar: Top 12 Hazards that Cause Injuries and Deaths

Calendar: Features real Washington State businesses and employees handling typical workplace hazards and spotlighting the top 12 hazards that cause injuries and deaths. It includes suggested weekly safety and health tips for different hazards, including slips trips and falls, struck by falling objects, burns and more.



Publicación
F417-248-000
 
Logger Safety Initiative Jobsite Notification

Members of the Logger Safety Initiative and landowners use this form to report their jobsite to L&I.



Formulario
F417-249-000
 
Bicycle Safety: Delivery, couriers, and messengers

Fact Sheet: Provides a summary of requirements and tips to ensure the safety of bicycle couriers, bicycle messengers and bicycle delivery riders. Includes a safety checklist.



Publicación
F417-250-000
 
2015 Workplace Safety and Health Calendar: Preventing Sprains and Strains - Washington’s Leading Workplace Injury

Calendar: Features real Washington State businesses and employees in jobs where sprains and strains are most common. The calendar includes suggested weekly safety and health tips for preventing sprains and strains to the neck, shoulders, back, hands/wrists, knees, and elbows.



Publicación
F417-251-000
 
Fall Hazards: Standing Walls - Highlights of Fall Protection Requirements

Safety Topic fact sheet: Describes the fall hazards workers are exposed to while framing, erecting and raising walls without using fall protection. Includes photos, safety requirements and different methods of fall restraints and fall arrest systems.



Publicación
F417-252-000
 
Application for Copies of Citation and Notice

Used by an employee to apply for copies of citation and notices issued to their employer.



Formulario
F418-023-000
 
Alleged Safety Or Health Hazards (DOSH Complaint Form)

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



Formulario
F418-052-000

Otro(s) idioma(s):
Español
 
Presuntos riesgos de Salud y Seguridad (Formulario de queja de la División de Seguridad y Salud Ocupacional)

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
 
Construction Checklist - Safety

Safety checklist for fall protection, ramps, stairways, ladders, trenches, excavations, scaffolds, personal protective equipment (PPE), electrical and chemical.



Checklist
F418-055-000
 
Application for Amusement Ride or Air Supported Structure Operating Permit

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



Formulario
F500-010-000
 
Application for Electrical Contractors License

Application used to get an electrical contractors license



Formulario
F500-018-000
 
Electrical/Telecommunications Contractor's Bond to the State of WA

Used to show proof of a bond in the State of Washington.



Formulario
F500-019-000
 
Electrical/Telecommunications Contractor Assignment of Savings Account

This is used to assign ownership interest to a savings account that is held by L&I for one year after a contractor's license has expired or after the contractor ceases business in Washington State.



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

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



Formulario
F500-032-000
 
Chapter 19.28 RCW - Electricians and Electrical Installations

Simplified version of the Chapter 19.28 RCW - Electricians and Electrical Installations Rules



Manual
F500-039-111
 
Electrical Safety Standards,Administration, and Installation WAC 296-46B

Electrical Safety Standards,Administration, and Installation WAC 296-46B



Manual
F500-039-222
 
Administrator / Electrician / Master Electrician Certificate Renewal

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



Formulario
F500-045-000
 
Application to Establish an Account and Access to L&I's Electrical Permit & Inspection System (EPIS) with L&I's Miscellaneous Accounts

To request access to L&I's EPIS - Miscellaneous Accounts



Formulario
F500-054-000
 
Application to Access L&I's Electrical Permit and Inspection System (EPIS) from SecureAccess Washington and Utilize Contractor Deposit Account via the Internet

To establish a contractor deposit account by an electrical contactor or registered construction contractors who are legally required to purchase electrical work permits from L&I.



Formulario
F500-055-000
 
Electrical Installation Variance Application

To apply for a variance which is an allowable deviation from specific requirements of a National Electrical Code section, or the WAC 296-46B where the proposed alternate methods will maintain equivalent safety.



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

Application to be certified as an amusement ride inspector.



Formulario
F500-065-000
 
Electrical Education Course Application

Used to get approval of a course as an electrical continuing education class. This application must be received by L&I at least 30 days before the course is offered.



Formulario
F500-068-000
 
Reassignment of Savings Account or Time Deposit - Electrical Contractor

A reassignment is permitted only when (1) the Electrical Contractor (assignor) changes the name of the business; (2) the Electrical Contractor transfers the funds to a new account; or (3) the financial institution changes the account number.



Formulario
F500-072-000
 
Electrical / Telecommunication Contractor's License Renewal Notice

This form is used to notify you that your license will expire and for you to use to renew your license.



Formulario
F500-077-000
 
Electrical Work on Residential Property: What You Should Know Before Work Begins
Fact Sheet: Explains to property owners the importance of electrical permits, inspections and approvals. An electrical permit is required for most new, remodel and maintenance electrical work.

Publicación
F500-078-000
 
Account Deposit for Contractor's or Miscellaneous Account Holder's

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



Formulario
F500-080-000
 
Electrical Inspection Witness Statement

Used to gather information from a person who was a witness to electrical work that is being investigated by L&I.



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

Use this form to apply for the master electrician exam.



Formulario
F500-088-000
 
Electrical Continuing Education Instructor Application

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



Formulario
F500-090-000
 
Contractor Electrical Work Permit Application

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



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

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



Formulario
F500-094-000
 
Application for a 0% Supervision Modified Electrical Training Certificate & Specialty Examination

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



Formulario
F500-097-000
 
Application for Specialty Electrician Certificate

Application and instructions for the specialty electrician certificate for 03A, 06B, 07A, 07B, 07C, 07D, 07E and 10. Eligibility granted through modified supervision requirements of RCW 19.28.191(1)(g)(ii)



Formulario
F500-098-000
 
Application for Accreditation of Engineer to Approve Industrial Utilization Equipment

Used by an Engineer to apply for accreditation by L&I to approve unlisted equipment.



Formulario
F500-101-000
 
Application for Pump Installer Combination General Contractor Registration and Electrical Contractor License

Used for creating combination electrical and plumbing contractors license



Formulario
F500-104-000
 
Electrical Work on Commercial Property: What You Should Know Before Work Begins
Fact Sheet: Explains to commercial property owners the importance of electrical permits, inspections and approvals. An electrical permit is required for most new, remodel and maintenance electrical work.

Publicación
F500-109-000
 
Questions and Answers about Electrical Safety
Fact Sheet: Answers questions about training and certification/licensing requirements for those who perform electrical installations, and electrical work that requires a permit and inspection.

Publicación
F500-110-000
 
Before Electrical Sign Work Begins: What Electrical Sign Contractors and Electricians Should Know
Fact Sheet: Explains work that is allowed and not allowed under (04) Sign Scope of Work and what electrical sign contractors and electricians should know before doing sign work. Also covers electrical Class B labels and electrical permits, inspections and fees.

Publicación
F500-111-000
 
Class B Labels: What You Should Know

Fact Sheet: Explains Class B label electrical work, scope and limitations, and provides general instructions for using Class B labels.



Publicación
F500-112-000
 
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
 
Electrical Program Contacts

Fact Sheet: Provides information for requesting electrical inspections, including telephone numbers and locations of L&I offices that handle electrical inspections.



Publicación
F500-114-000
 
Electrical Safety Tips for Your Home: Protect Your Family and Your Property
Pamphlet/Booklet: Provides information to help consumers properly handle electrical equipment and appliances, know the required permits and inspections for electrical work, and verify licenses and certifications before having electrical work performed.

Publicación
F500-115-000
 
Green Power Generation System Installation: What You Should Know Before Doing Any Electrical Work
Fact sheet: Explains that an electrical permit and inspection are required for most new, remodel, and maintenance electrical work. Provides information specific to the installation of green power generation systems.

Publicación
F500-116-000
 
How to Become a Certified Electrician: What You Need to Know about Certification in Washington State
Fact sheet: Provides information about getting a trainee card and outlines the electrical training and experience required to be certified as an electrician in Washington State.

Publicación
F500-117-000
 
An Annual Electrical Permits Saves Time and Money. Would it Work for You?

Flier: Describes when facility operators/owners qualify for an annual electrical permit.



Publicación
F500-123-000
 
Electrical Telecommunication Principal Member Owner Update Request

Electrical Telecommunication Principal Member Owner Update Request



Formulario
F500-124-000
 
HB 2253 Open Window Opportunity - Affidavit of Hours of Unsupervised Telecommunications Installation Experience

This form is not available until June 12.



Formulario
F500-127-000
 
Application for Telecommunications Contractor's License

Application used to get an telecommunications contractors license.



Formulario
F503-008-000
 
Non-Compliance Report - Boiler & Pressure Vessel Inspection

Used by L&I inspectors when a boiler or pressure vessel does not pass inspection. You can only mail or fax this form to L&I. E-mailed forms are NOT accepted.



Formulario
F620-012-000
 
Board of Boiler Rules Interpretation and Revision Request Form

Used to submit written requests for interpretations and revisions to the definitions, rules and regulations found in WAC 296-104. These must be submitted 45 days prior to the Board of Boiler Rules Meeting date. F620-056-000 Chief Inspector Clarification and Interpretation Request Form must be submitted before using this form.



Formulario
F620-017-000
 
Operating Boilers Safely
Fact sheet: Explains what you need to know to keep your boilers and pressure vessels operating safety. Provides an overview of inspection requirements, frequency and fees.

Publicación
F620-025-000
 
Shop and Field Inspection Report

Used by L&I inspectors when they inspect boilers.



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

Formulario
F620-032-000
 
Application for Certificate of Competency as an Inspector of Pressure Retaining Items

To apply for a certificate of competency as an Inspector of Pressure Retaining items. You can only mail or fax this form to L&I. Emailed forms are not accepted. NOTE: Applications MUST be received no later than 30 days prior to the exam date. Incomplete applications WILL NOT be accepted.



Formulario
F620-040-000
 
Boiler/Pressure Vessel Clearance Variance Request

To request a clearance variance on a boiler or pressure vessel. You can only mail or fax this form to L&I. E-mailed forms are not accepted.



Formulario
F620-041-000
 
Rental Boiler Operating Permit - Good at this Location Only

To request a permit to use a rental boiler at one location only.

Allow 24 hours for a response. Accuracy and completeness speeds up the processing time.



Formulario
F620-042-000
 
Historical Boilers Inspection Guideline

Inspection sheet for boiler inspectors. 4 pages.



Formulario
F620-043-000
 
Incident Report Boiler or Pressure Vessel

Used for the reporting of incident with boilers or a pressure vessels.



Formulario
F620-044-000
 
Pre-Inspection Checklist for Hot Water Heating or Hot Water Supply Boilers

Checklist which reflects the most common violations encountered by Field Inspectors. This checklist should be gone through prior to requesting inspection of Hot Water Heating or Hot Water Supply Boilers



Checklist
F620-050-000
 
Pre-Inspection Checklist for Potable Water Heaters - ASME "HLW" Stamped Water Heaters

Checklist which reflects the most common violations found by Field Inspectors. This checklist should be gone through prior to calling for an inspection of Potable Water Heaters-HLW



Checklist
F620-051-000
 
Pre-Inspection Checklist for Low Pressure Steam Boilers

Checklist which reflects the most common violations found by Field Inspectors. This checklist should be gone through prior to calling for an inspection of Low Pressure Steam Boilers



Formulario
F620-052-000
 
Pre-Inspection Checklist for High Pressure Boilers

Checklist which reflects the most common violations found by Field Inspectors. This checklist should be gone through prior to calling for an inspection of High Pressure Boilers



Formulario
F620-053-000
 
Board of Boiler Rules Extension of Inspection Frequency Request Form

Board of Boiler Rules Extension of Inspection Frequency Request Form



Formulario
F620-055-000
 
Chief Inspector Clarification and Interpretation Request Form

Form is used to ask the Chief Inspector to consider written requests for clarification and interpretation to the definitions, rules and regulations in WAC 296-104. Thsi form must be completed before F620-017-000 Board of Boiler Rules Interpretation and Revision Request form can be submitted.



Formulario
F620-056-000
 
Board of Boiler Rules Washington State Specials Request Form

Board of Boiler Rules Washington State Specials Request Form



Formulario
F620-057-000
 
Faulty Water Heaters and Kids Don't Mix
Fact sheet: Designed for operators of childcare facilities, this fact sheet explains the importance of keeping boilers and pressure vessels operating safety. Provides an overview of inspection requirements, frequency, and fees.

Publicación
F620-059-000
 
Inservice Inspection checklist

Inservice Inspection checklist for power boilers, low pressure boilers, pressure vessels, and hot water boilers.



Formulario
F620-060-000
 
Construction Elevator Installation Application and Inspection Data Report

Used by companies to apply for an Construction Elevator (Hoist) at a job site. One application per car and companies need to contact the Elevator Section for the appropriate installation and operating fee.

Allow two weeks for a response. Accuracy and completeness speeds up the processing time.



Formulario
F621-001-000
 
Installation Application for Elevators

Used for installation application for elevators (new, renewals, and alterations).

Allow 30 business days for a response. Accuracy and completeness speeds up the processing time.
 
Residential Incline Chair Lifts: Allow one week for a response.



Formulario
F621-005-000
 
Elevator Installation Variance Application

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

Allow 4-6 weeks for a response.  Accuracy and completeness speeds up the processing time.



Formulario
F621-048-000
 
Elevator Information Update

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



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

This report is used by elevator company mechanics and left on the job site for review by elevator inspectors.



Formulario
F621-051-000
 
Hydraulic Overpressure Test

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



Formulario
F621-052-000
 
Test of Escalator Safety Devices

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



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

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



Formulario
F621-056-000
 
New Elevator Installation Checklist

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



Formulario
F621-057-000
 
Request for Duplicate Elevator Certificate

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



Formulario
F621-065-000
 
Application for Licensure as an Elevator Mechanic

This is an application for certification as an Elevator Mechanic and is NOT a license to perform work. A contractor's license is still required by L&I.



Formulario
F621-067-000
 
Temporary Licensed Elevator Mechanic

This temporary license is limited to the mechanical and electrical operation, construction, installation, alteration, maintenance, inspection, relocation and repair of conveyances.



Formulario
F621-068-000
 
Licensed Elevator Contractor (LC) Operation

Contractors who install, construct, repair, alter or maintain elevators need to be licensed by the Elevator Program through L&I and with L&I's contractor registration program.



Formulario
F621-069-000
 
License Requirements for Elevator Mechanics and Contractors
Fact sheet: Explains licensing and testing requirements for mechanics who work on elevators and for contractors who install, repair or maintain elevators.

Publicación
F621-070-000
 
Elevator Continuing Education Course Application

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



Formulario
F621-077-000
 
Elevator Continuing Education Provider / Instructor Application

Application to become an instructor or provider for elevator related courses.



Formulario
F621-078-000
 
Renewal of Elevator Mechanic License

Used by elevator mechanics to renew their license if they do not want to use the online "Get or Renew a License".



Formulario
F621-080-000
 
Renewal of Contractor Elevator License

Used by Elevator Companies to renew their Contractor License.



Formulario
F621-082-000
 
How to Ride Safely on Elevators, Escalators and Moving Walks
Pamphlet/booklet: Provides safety tips and interesting facts to promote safe use of elevators, escalators and moving walks.

Publicación
F621-084-000
 
New/Update Elevator Company Primary Point of Contact

Used by the Elevator Section only to Change and/or Update the Primary Point of Contact for Elevator Companies



Formulario
F621-086-000
 
Application to Utilize Contractor Deposit (CD) Account

The contractor requests to set up an L&I Contractor Deposit Account (CD) which is established for businesses that are licensed by the department as elevator contractors.



Formulario
F621-094-000
 
ELEVATOR ACCOUNT DEPOSIT FOR CONTRACTOR’S OR MISCELLANEOUS ACCOUNT HOLDER’S

ELEVATOR ACCOUNT DEPOSIT FOR CONTRACTOR’S OR MISCELLANEOUS ACCOUNT HOLDER’S



Formulario
F621-098-000
 
Request for Duplicate Elevator Mechanic License

Request for Duplicate Elevator Mechanic License



Formulario
F621-099-000
 
Elevator Mechanic and Elevator Temporary Mechanic Address/Mailing Information Update

Elevator Mechanic and Elevator Temporary Mechanic Address/Mailing Information Update



Formulario
F621-100-000
 
Plan Approval Request - Recreational Vehicles and Recreational Park Trailers

Plans to build recreational vehicles or park trailers need approval from L&I. This form is used as part of the approval process.



Formulario
F622-006-000
 
Alteration Fire Safety Pre-Inspection Checklist

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



Checklist
F622-011-000

Otro(s) idioma(s):
Español
 
Lista de comprobación para la preinspección de seguridad contra incendios

Lista de comprobación para dueños de casas sobre cómo mejorar sus casas antes de la preinspección del Departamento de Vivienda y Desarrollo Urbano (HUD, por su sigla en inglés) para alcanzar los estándares en el área de seguridad contra incendios.



Formulario
F622-011-999

Otro(s) idioma(s):
Inglés
 
Electric / Gas Conversion Pre-Inspection Checklist

This checklist is generic in content and may not include all requirements for your particular installation. The manufacturer's installation instruction must be adhered to and available to the inspector at the time of the inspection.



Checklist
F622-013-000
 
Air Conditioner/Heat Pump Pre-Inspection Checklist

This checklist is designed to be generic in content and may not include all requirements for your particular installation.



Checklist
F622-014-000
 
Wood / Pellet Stove / Fireplace Pre-Inspection Checklist

This checklist is designed to be generic in content and may not include all requirements for your particular installation.



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

To apply for an insignia for a recreational vehicle.



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

Continuation sheet to apply for an insignia.



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

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



Formulario
F622-035-000
 
Factory Assembled Structures Alteration Application

Used by a homeowner or contactor to request a field inspection for an alteration to a manufactured or mobile home.

Allow 1-2 days for a response to alteration applications for Manufactured/Mobile Homes.

All other alteration applications, allow 2-3 weeks for a response. Accuracy and completeness speeds up the processing time.



Formulario
F622-036-000
 
Low Voltage Fire / Intrusion Alarm Checklist

This checklist is designed to be generic in content and may not include all requirements for your particular installation.



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

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



Checklist
F622-039-000
 
Flood Damaged Manufactured Home Checklist

Checklist on how to repair a flood damaged manufactured home. After the contractor has done all that is required by the checklist they call L&I for an inspection.



Checklist
F622-040-000
 
Is it a Manufactured / Mobile Home?

If your home has any of the items in this document, it is a manufactured / mobile home and requires inspections for all alterations by L&I's Factory Assembled Structures Section.



Formulario
F622-043-000
 
Steel or Wrought-Iron Gas Line Pre-Inspection Checklist

This checklist is used by the contractor when installing steel or wrought-iron gas line. Be sure you can answer YES to all questions before calling L&I for an inspection.



Checklist
F622-044-000
 
Gas Room Heaters Pre-Inspection Checklist

This checklist is used by the contractor when installing gas room heaters. Be sure you can answer YES to all questions before calling L&I for an inspection.



Checklist
F622-045-000
 
Copper Tubing Gas Line Pre-Inspection Checklist

This checklist is used by the contractor when installing gas lines with copper tubing. Be sure you can answer YES to all questions before calling L&I for an inspection.



Checklist
F622-046-000
 
Your Manufactured/Mobile Home

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



Publicación
F622-049-000

Otro(s) idioma(s):
Español
 
Casas prefabricadas y móviles: lo que los dueños de casas y contratistas deben saber al modificar una vivienda

Folleto: Cubre asuntos que usted debe considerar al modificar su casa. Define lo que significa modificación, reparación y sustitución e incluye consejos para contratar contratistas registrados. También incluye información de comunicación para el Programa de L&I para Asistencia al Consumidor para dueños de casas prefabricadas /móviles.



Publicación
F622-049-999

Otro(s) idioma(s):
Inglés
 
Alteration Polybutylene Re-Pipe Pre-Inspection Checklist

This checklist is used by the contractor when altering a polybutylene re-pipe. Be sure you can answer YES to all questions before calling L&I for an inspection.



Checklist
F622-053-000
 
Homeowners Manufactured / Mobile Home Variance Request

This variance request applies only to the installations performed by a previous owner and does not apply to any home during the warranty period.



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

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



Formulario
F622-063-000
 
Vendor / Medical Conversion Units Pre-Inspection Checklist

Pre-Inspection Checklist to assist vendor owners, manufacturers, and others on what they need to know to get their vendor/medical unit approved by Labor and Industries.



Formulario
F622-072-000
 
RCW 43.22.380 Exemptions Fire and Safety Checklist for Vendor/Medical Conversion Units
Generic Checklist to determine if the particular installation includes all requirements prior to calling for an inspection. Must be able to answer YES to all questions prior to calling.

Formulario
F622-073-000
 
Structural Inspection Request Questionnaire

Structural Inspection Request Questionnaire



Formulario
F622-075-000
 
Roof Affidavit and Structural Inspection Request

The purpose of the manufactured home roof affidavit is to provide timely inspections and communications between the contractor and/or owner and FAS inspectors and field staff.

A structural inspection request questionnaire will not be required when a roof change out occurs if no structural changes are made in the roof sub-surface and roof cavity. Example: Repairing or replacing the roof trusses, rafters, ridge beam and the replacement of not more than (4) 4’x 8’ of roof sheathing.



Formulario
F622-076-000
 
Manufactured Home Installer Certification Tag Order form

Manufactured Home Installer Certification Tag Order form



Formulario
F622-077-000
 
Manufactured Home Installer's Monthly Certification Tag Report

Manufactured Home Installer's Monthly Certification Tag Report



Formulario
F622-078-000
 
Manufactured Home Installer Certification Tag Transfer Request form

Manufactured Home Installer Certification Tag Transfer Request form



Formulario
F622-079-000
 
Minimum Header Structural Requirements for Manufactured Home Alterations

For use on sidewalls only. Maximum of one new opening up to 11-6 wide per sidewall. Edge of opening to be no closer than 4 from end of sidewall.



Formulario
F622-080-000
 
Account Deposit for Factory Assembled Structures Account Holders

You must have a contractor license number or have completed an application for a miscellaneous account to use this form.



Formulario
F622-081-000
 
Plan Approval Request - Factory Built Structures and Commercial Coaches

A manufacturer of factory-built structures and/or commercial coaches uses this form to submit plans to L&I for review.



Formulario
F623-006-000
 
Notification to Local Enforcement Agency

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



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

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



Formulario
F623-014-000
 
Panel Load Calculations

Listing of Connected Loads and the Demand Loads. Used for all appliances that are fastened in place, permanently connected on specific circuit. Single Phase Panel Schedule and Three Phase Panel Scheule inlcude. Sample diagram included.



Formulario
F623-017-000
 
Application for Insignia for Commercial Coaches

Manufacturer uses this form to apply for an official insignia for commercial coaches that have a plan approval number.



Formulario
F623-019-000
 
Application for Insignia Conversion Vendor/Medical Units

Used to apply for an official insignia for conversion vendor or medical unit factory-assembled structures. See sample form for instructions about how to fill out the form correctly.



Formulario
F623-021-000
 
Application for Construction Contractor Registration

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



Formulario
F625-001-000
 
Assignment of Account - WA State Banks Only

Contractors may use this form to request an Assignment of Account in lieu of a surety bond. The amount of the surety bond would need to be placed into an account at a WA State Bank.



Formulario
F625-008-000
 
Facts About Construction Liens
Fact sheet: Explains the basics of the construction lien law to help consumers protect themselves.

Publicación
F625-017-000
 
Waiver of Lien by Contractor, Subcontractor(s) and Supplier

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



Formulario
F625-029-000
 
Model Disclosure Statement Notice to Customer

This disclosure statement is given to the consumer (customer) from the contractor showing they are registered in the state of Washington. The consumer (customer) signs this form as acknowledgement of receipt.



Formulario
F625-030-000
 
Contractor Complaint Form

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



Formulario
F625-033-000
 
Contratistas de Construcción: Obtenga los Datos, Regístrese

Folleto: Explica los pasos para registrarse como contratista de construcción en el estado de Washington.



Publicación
F625-040-999

Otro(s) idioma(s):
Inglés
 
Subscription Request for Construction Contractor and Electrical Basic - CD

This form is to be used to purchase the CD ROM of registered construction contractors, registered electrical contractors, plumbers and electricians.



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

Instructions for filing suit against an electrical contractor



Formulario
F625-053-000
 
Construction Lien Notice

This form is to be used by suppliers to notify homeowners that they have the ability to file a construction lien against their property if payment is not received.



Formulario
F625-054-000
 
Construction Lien Summary

General requirements that a lien claimant of a private construction project (not a commercial) must meet. This is intended show the general requirements for most lien claimants.



Formulario
F625-055-000
 
Contractor Financial Information

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



Formulario
F625-061-000
 
Affidavit to Release Public Records

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



Formulario
F625-066-000
 
Construction Contractor's Application for Workers' Compensation Account with No Workers or Hours

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



Formulario
F625-077-000
 
Assignment of Account or Time Deposit for Insurance - Bodily Injury - WA State Banks Only

Contractors may use this form to request an Assignment of Account in lieu of an insurance policy for bodily injury. The amount of the insurance policy would need to be placed into an account at a WA State Bank.



Formulario
F625-082-000
 
Assignment of Account or Time Deposit for Insurance - Property Damage - WA State Banks Only

Contractors may use this form to request an Assignment of Account in lieu of an insurance policy for property damage. The amount of the insurance policy would need to be placed into an account at a WA State Bank.



Formulario
F625-083-000
 
What You Should Know About Hiring a Contractor, Remodeler, or Handyman

Pamphlet/booklet: Provides a checklist for consumers considering hiring a general or specialty construction contractor, reviews the permitting process, and suggests ways to avoid lien problems. Washington State law requires contractors to register with L&I.



Publicación
F625-084-000

Otro(s) idioma(s):
Español
 
Lo que Usted Debe Saber para Contratar a un Contratista, Remodelador o Empleado de Mantenimiento (Handyman)  

Hoja de información:  Proporciona una lista de verificación para los consumidores que están considerando contratar un contratista general o con especialidad, revisa el proceso de autorización y sugiere maneras para evitar problemas con gravámenes.  La ley estatal de Washington requiere que los contratistas de construcción se registren con L&I.



Publicación
F625-084-999

Otro(s) idioma(s):
Inglés
 
What to Do if You Want to File Suit Against Your Construction Contractor

Fact sheet: Provides consumers with general information about the process for filing suit, and describes L&I's limited role in serving Summons & Complaint papers.



Publicación
F625-088-000
 
Washington Contractor's License Bond Validation Rider

This rider is intended to be used in conjunction with a bond.



Formulario
F625-098-000
 
Washington Contractor's License Bond Name Change Rider

Used by the bond company to change the name of the contractor's business.



Formulario
F625-099-000
 
Washington Contractor's License Bond License Number Change Rider

Used by the bond company to change the contractor's business license number.



Formulario
F625-100-000
 
Washington Contractor's License Bond Date Change Rider

Used by the bond company to change the effective date of the contractor's bond.



Formulario
F625-101-000
 
Washington Contractor's License Bond Bond Amount Rider

Used by the bond company to amend the amount of the contractor's bond.



Formulario
F625-102-000
 
Washington Contractor's License Bond Entity Change Rider

Used by the bond company to show a change in the business structure of a contractor's business.



Formulario
F625-103-000
 
Washington Contractor's License Bond Address Change Rider

Used by the bond company to change the address of the contractor's business.



Formulario
F625-104-000
 
Renewal Application for Contractor Registration

Renewal Application for Contractor Registration



Formulario
F625-107-000
 
Contractor Registration Request for Duplicate License or Address Change  

This form may be faxed to the Contractor Registration office in Tumwater.



Formulario
F625-108-000
 
Application for Agent On-Line Insurance Entry Account

Application for Agent On-Line Insurance Entry Account



Formulario
F625-110-000
 
Upgrade from Specialty Contractor to General Contractor

Used to apply for an upgrade from Specialty Contractor to a General (01) Contractor.



Formulario
F625-113-000
 
Stop illegal contracting: See it? Report it.

Brochure: Aimed at construction contractors, this publication tells how to report cases of suspected fraud by construction contractors. Explains how fraud hurts legitimate construction contractors and consumers. Includes description of the online "Verify" tool, which allows people to check whether a contractor is registered and other information about the contractor.



Publicación
F625-114-000
 
Application for Electrician Examination

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



Formulario
F626-001-000
 
Application / Renewal for an Electrical Training Certificate

This the application for an Electrical Training Certificate or the renewal of. (This does NOT make you a registered apprentice).



Formulario
F626-048-000
 
Application for Plumber Trainee Certificate

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



Formulario
F627-003-000
 
Affidavit of Experience - Plumbers

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



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

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



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

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



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

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



Formulario
F627-019-000
 
Facts about State Certification for Plumbers
Fact sheet: Explains plumber classifications, certification requirements, including required exams, and the application and renewal processes, including continuing education requirements.

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

Publicación
F627-026-000
 
Plumbers Examination Dates and Locations

The 2014 and 2015 Plumber Examination Dates and Locations. A printed version of the 2014 Plumber Examination Dates and Locations is also available from the L&I Warehouse.



Formulario
F627-027-000
 
Application for Backflow Trainee Certificate

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



Formulario
F627-033-000
 
Application for Backflow Specialty Exam

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



Formulario
F627-035-000
 
Plumber Continuing Education Course Application

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



Formulario
F627-037-000
 
Plumber Request for Change of Address

Plumber Request for Change of Address



Formulario
F627-039-000
 
Affidavit of Continuity Medical Gas Installation

Affidavit of Continuity



Formulario
F627-043-000
 
Hiring a Plumber? Hire Smart!

Worksheet: Provides advice and step-by-step hiring tips for homeowners planning a remodel, repair or addition to their home that involves plumbing. Tells homeowners how to verify that a construction contractor is registered and a plumber is certified with the state.



Publicación
F627-044-000
 
Parent / School Authorization for Employment of a Minor and Special Variance

For legal guardians and school officials to approve the hours and work activities for a minor employee to work according to terms listed by the employer. The Special Variance allows additional hours of work for 16- and 17-year-olds and is described on the form. All parties must sign to approve the hours of work for a minor regardless of the number of hours listed. This is NOT a work permit. Employers must obtain a minor work permit endorsement on their Master Business License where they employ workers under 18.

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



Formulario
F700-002-000
 
Affidavit of Wages Paid - Public Works Contract and Instructions

This form is a fillable Word document that is used by a contractor, company or agency to show the wages paid to employees on a public works project. The best way to use this document is to bookmark this page as a “Favorite” in your web browser. Then each time when you want to use the document, access the online version of the form. This will ensure you are always utilizing the most recently published form. (We recommend you not download the document and save the form for future use because we may make changes to the form that your downloaded version will not contain.) You must file the Affidavit of Wages Paid form when you have completed your portion of a public works job/project. Addendum A is form number F700-161-000, Addendum C is form number F700-162-000, and the EHB 2805 (RCW 39.04.370) Addendum is form number F700-164-000.



Formulario
F700-007-000
 
Record Keeping Provisions - Employment Standards

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



Formulario
F700-009-000
 
Operating Power Lawn and Yard-care Equipment: Safety for Teen Workers
Fact sheet: Overview of safety practices, plus information on what equipment employees under 18 can and cannot operate. Provides resources on requirements for hearing protection and PPE (personal protective equipment).

Publicación
F700-010-000
 
Application for Farm Labor Contractor License

Used to apply or renew a license.



Formulario
F700-014-000
 
Teens at Work: Facts for Employers, Parents and Teens

Pamphlet/booklet: Answers questions employers, parents and teens may have about employing teen workers (ages 14-17). Explains non-agriculture work rules, including the necessary permits, hours and work conditions. Provides links to other resources.



Publicación
F700-022-000

Otro(s) idioma(s):
Español
 
Adolescentes en el trabajo: información para empleadores, padres y adolescentes

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
 
Statement of Intent to Pay Prevailing Wages - Public Works Contract

This form is a fillable Word document that is used by a contractor, company or agency upon accepting work on a public works project. The best way to use this use this document is to bookmark this page as a “Favorite” in your web browser. Then each time when you want to use the document, access the online version of the form. This will ensure you are always utilizing the most recently published form. (We recommend you not download the document and save it for future use because we may make changes to the form that your downloaded version will not contain.) You should file this form immediately after the contract is awarded and before you begin work. Form number F700-160-000 is addendum A and F700-163-000 is addendum C.



Formulario
F700-029-000
 
Washington State Prevailing Wage Law

Booklet: Contains the prevailing wage laws (RCWs) and rules (WACs) as well as plain language descriptions and contact information.



Publicación
F700-032-000
 
Agreement - Farm Labor Contractors and Workers

Employment wages and conditions agreement with Farm Labor Contractors and Workers



Formulario
F700-046-000

Otro(s) idioma(s):
Español
 
Acuerdo entre contratistas agrícolas y trabajadores

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



Formulario
F700-046-999

Otro(s) idioma(s):
Inglés
 
Minimum Wage Law Exemptions

Covers exemptions to Washington state minimum wage law.



Publicación
F700-051-000
 
Employer Rights - Wages Paid

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



Formulario
F700-058-000
 
Farm Labor Contractor Assignment of Account or Time Deposit

Farm Labor Contractor assignment of account or tme deposit for employee



Formulario
F700-060-000
 
Certified Project Payroll

There are instructions in one PDF file, and a blank form that may be printed in the other PDF. The word document is saved in Microsoft 2003 format and is a fillable word form.



Formulario
F700-065-000
 
Farm Labor Contractors Bond

Notarized farm labor contractors bond coverage.



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

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



Publicación
F700-067-000
 
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/español)

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/español)

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: Da un resumen de 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 cubre 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 otros sectores en el estado de Washington deben colocar este cartel donde los trabajadores puedan verlo.

Por favor solicítelo de L&I o imprímalo en papel de tamaño 11x17 pulgadas.

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
 
Washington State OverTime Law

Covers compensation for employees in Washington State working overime.



Publicación
F700-079-000
 
Nonagricultural Employment of Minors Chapter 296-125 WAC

Nonagricultural Employment of Minors Chapter 296-125 WAC



Manual
F700-084-000
 
Estándares de Trabajo Agrícola Capítulo 296-131 del Código Administrativo de Washington (WAC, por su sigla en inglés)

Documento Legal: Estándares de trabajo agrícola - Capítulo 296-131 del Código Administrativo de Washington (WAC, por su sigla en inglés)



Manual
F700-085-999

Otro(s) idioma(s):
Inglés
 
Farm Labor Contractor Registration

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



Publicación
F700-088-000

Otro(s) idioma(s):
Español
 
Registro para un contratista de trabajadores agrícolas

Hoja de información:  Explica cómo obtener una licencia de contratista agrícola para poder operar legalmente como un contratista agrícola en el estado de Washington.



Publicación
F700-088-999

Otro(s) idioma(s):
Inglés
 
Variance Application - Employment Standards

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



Formulario
F700-089-000
 
Minimum Wage Law - Truck Drivers

Record keeping provisions and overtime for truck & bus drivers.



Publicación
F700-095-000
 
Young Workers in Agriculture / Trabajadores jóvenes en la agricultura (English/español)

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.

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
 
Washington State Deduction Laws

Deductions for current & terminated employees and employer liability for paying less than required.



Formulario
F700-097-000
 
Internal Revenue Service Tax Compliance Certification

Form to gain Internal Revenue Service Tax Compliance Certification for registered Farm Labor Contractors. Now includes IRS form 8821 Tax Information Authorization.



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

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



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

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



Formulario
F700-100-000
 
Your Daily Record of Hours Worked / Su registro de horas trabajadas (English/español)

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

Folleto: Un librito bilingüe de tamaño bolsillo para animar a los trabajadores a mantener un registro de sus horas de trabajo diarias y de sus ingresos.



Publicación
F700-105-909
 
Farm Labor Contractor Complaint Form

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



Formulario
F700-109-000

Otro(s) idioma(s):
Español
 
Formulario de queja en contra de un contratista de trabajores agrícolas

Usado para presentar una queja contra un contratista agrícola,  hacendado, empleador u otro en lo que se refiere a una infracción.



Formulario
F700-109-999

Otro(s) idioma(s):
Inglés
 
Farm Labor Contractor Checklist

Farm Labor Contractor's Checklist to ensure compliance.



Formulario
F700-112-000

Otro(s) idioma(s):
Español
 
Lista de comprobacion para un contratista de trabajores agrícolas

Lista de comprobación para el contratista de trabajadores agrícola para asegurar el cumplimiento.



Formulario
F700-112-999

Otro(s) idioma(s):
Inglés
 
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
 
Court Form Granting Permission for Employment of Minors

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



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

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



Formulario
F700-120-000
 
Application for House to House Sales Sales Employer Registration Certificiate

Used by employers to register as employing minors who will be engaged in house-to-house sales, as required by WAC 296-125-024, with Labor and Industries.



Formulario
F700-121-000
 
Application for Special Certificate to Employ A Vocationally Handicapped Worker at at Subprevailing Wage Rate

Employer Application for Special Certificate to Employ A Vocationally Handicapped Worker at at Subprevailing



Formulario
F700-122-000
 
Summary of Agricultural Employment Regulations and Farm Contractor Requirements

This summary is on employment laws relating to the agricultural industry.



Publicación
F700-124-000
 
Agricultural Employer Worksheet

Used by agricultural employers to assist them in determining if they are following the state Agricultural Employment Standards and the Minimum Wage Act for their employees.



Formulario
F700-125-000
 
Interested Party Checklist for the Filing of Prevailing Wage Complaints

Checklist used for the filing of Prevailing Wage Complaints by "Interested parties" ONLY.



Formulario
F700-129-000
 
Seasonal Group Variance Application

Used for Exceptions from the Hours of Work for Minors for Seasonal work.  Complete the form, print it, sign it and fax or mail it to the address at the top of the form. Variance Application forms may be faxed to (360) 902-5300. If you would like the approved Variance Certificate faxed back to your business, please state so on your cover sheet.



Formulario
F700-135-000
 
Congratulations! You've been approved to hire minors
Card: Reminds employers of special work rules for employees under age 18. Lists key points and provides a Web address for where to find more detailed information. Sent to all employers who obtain a minor work permit endorsement on the master business license.

Publicación
F700-136-000
 
Safety Steps for Supervisors and Employees in Restaurants
Fact Sheet: A useful summary of the responsibilities both employers and employees share for a safe workplace. This can be shared with new employees during their initial orientation.

Publicación
F700-139-000
 
Restaurant Employee Safety Orientation Checklist
Fact Sheet: Download this checklist to help with the safety orientation of new restaurant employees.

Publicación
F700-140-000
 
Request for Assistance in Obtaining Certified Payroll Records

Used to request copies of Certified Payrolls for prevailing wage projects.



Formulario
F700-141-000
 
Hiring teens? / ¿Piensa contratar adolescentes? (English/español)

Fact sheet: Provides important information about hiring teens, including extra safety precautions, as well as legal requirements regarding minor work endorsement, hours and prohibited duties. Provides telephone, e-mail and Web contacts for more information.

Hoja de información:  Proporciona información importante sobre la contratación de adolescentes, incluyendo precauciones adicionales de seguridad, así como también los requisitos legales referentes al endoso de trabajo para menores, horas y tareas prohibidas.  Proporciona un teléfono, correo electrónico y contactos en la página Web para más información.

 



Publicación
F700-142-909
 
Affidavit of Wages Paid Addendum B List of Next Tier Subcontractors - Public Works Contract

Copies of the 05-2008 version will be available in the warehouse later in July.



Formulario
F700-143-000
 
Protected Leave Complaint

For leave from work complaints: Download and complete a Protected Leave Complaint form (F700-144-000)



Formulario
F700-144-000

Otro(s) idioma(s):
Español
 
Queja sobre el permiso de ausencia protegida

Para quejas de ausencia del trabajo: Descargue y complete un Formulario de queja sobre permiso de ausencia protegida (Número F700-144-999)



Formulario
F700-144-999

Otro(s) idioma(s):
Inglés
 
Youth in Construction / Adolescentes en construcción  (English/español)

Booklet/pamphlet: Explains the limits on work teens under age 18 can perform in the construction industry, discusses the importance of training and emphasizes safety. Includes a checklist of "do's" and "don'ts" for employers, plus other resources.

Pamfleto:  Explica los límites en los trabajos que los adolescentes menores de 18 años de edad pueden desempeñar en la industria de la construcción, discute la importancia de la capacitación y enfatiza la seguridad.  Incluye una lista para empleadores de lo que los adolescentes pueden y no pueden hacer además de otros recursos.



Publicación
F700-145-909
 
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
 
Farm Labor Contractor Certified Payroll

Form used to document Farm Labor Contractor payroll for piece rate, hourly rate, or both.



Formulario
F700-147-000
 
Worker Rights Complaint Form

This is the Worker Rights Complaint Form. Both the 12-2011 and 10-2010 versions are valid.



Formulario
F700-148-000

Otro(s) idioma(s):
Español
 
Formulario de queja sobre los derechos laborales

Formulario: queja sobre los derechos laborales.  Las versiones de octubre de 2010 y de diciembre 2011 son válidas.



Formulario
F700-148-999

Otro(s) idioma(s):
Inglés
 
Wage-and-Hour Questions Employers Often Ask

Fact sheet: Provides answers to questions related to pay requirements, deductions from pay, hiring a teen worker, employee uniforms and access to personnel file. Includes contact information if an employer needs assistance with a specific situation.



Publicación
F700-150-000
 
Resumen de las Leyes de Salario Prevaleciente en lenguaje sencillo - entienda sus responsabilidades y derechos al hacer trabajos públicos

Hoja de información:  Documento con las medidas de 8.5 pulgadas x 11 pulgadas tamaño carta. Proporciona un resumen de las leyes y normas del salario prevaleciente en español.  Esta publicación está solamente disponible en español.  Para información similar en inglés, lea el folleto de la Ley de Salario Prevaleciente del estado de Washington.



Publicación
F700-152-999
 
What You Need to Know if You Don't Get Paid: A Worker's Guide to the Washington State Wage Payment Act / Lo que necesita saber si no recibe su pago: una guía para el trabajador de la ley del pago de salario del estado de Washington (English/español)

Fact sheet: Summarizes workers' rights and responsibilities regarding minimum wage, pay, work hours and overtime and explains how to file a wage complaint. Includes answers to several commonly asked questions.

Hoja de información:  Hace un resumen de los derechos y responsabilidades de los trabajadores referentes al salario mínimo, pago, horas trabajadas y horas extras y explica cómo presentar una queja de salario, incluye respuestas a varias preguntas frecuentes.



Publicación
F700-153-909
 
Avoid Liability for Your Farm Labor Contractor's Unpaid Debits / Evite su obligación por las deudas no pagadas de su contratista de trabajadores agrícolas (English/español)

Fact sheet: Explains how employers could be liable for unpaid workers' compensation premiums, unpaid wages, damages and civil penalties when hiring a farm labor contractor. Outlines ways to protect against potential liability.

Hoja de información:  Explica cómo los empleadores pueden ser responsables por las primas de compensación para los trabajadores, salarios no pagados, daños y multas civiles al contratar un contratista agrícola.  Indica maneras para protegerse contra una posible responsabilidad.

 



Publicación
F700-154-909
 
Application for Farm Internship

Application form: Small farm owners wishing to participate in the pilot small farm internship program must complete this form and submit it to the department. The information requested on the form is required to process an application for approval in order to issue a certificate of participation.



Formulario
F700-158-000
 
Statement of Intent to Pay Prevailing Wages Addendum A

Please use this addendum to list additional Crafts/Trades/Occupations when you need to add more Crafts/Trades/Occupations than the Statement of Intent to Pay Prevailing Wages form can accommodate. Addendum A is for form F700-029-000.



Formulario
F700-160-000
 
Affidavit of Wages Paid Addendum A Additional List of Crafts

Please use this addendum to list additional Crafts/Trades/Occupations when filing an Affidavit of Wages of Paid and you need to list more Crafts/Trades/Occupations than the Affidavit of Wages Paid form can accommodate. This is the addendum A to form F700-007-000.



Formulario
F700-161-000
 
Affidavit of Wages Paid Addendum C Additional Information

Please use this addendum to provide any additional information you want to communicate to L&I when you file an Affidavit of Wages of Paid. Addendum C is for form F700-007-000.



Formulario
F700-162-000
 
Statement of Intent to Pay Prevailing Wages Addendum C

Please use this addendum to provide any additional information you want to communicate to L&I when you file a Statement of Intent to Pay Prevailing Wages. Addendum C is for form F700-029-000.



Formulario
F700-163-000
 
Student Learner Variance Application

Employer uses this application form for requesting a variance to employment regulations for minors enrolled in a work-based learning placement. It can be used for individual or multiple minors for the same employer.



Formulario
F700-166-000
 
Employing teens under 18 in food service? - L&I’s fact sheet of permitted and prohibited work activities for youth ages 14 to 17 in food service

Fact sheet: Explains permitted and prohibited work activities for youth ages 14 to 17 in food service. Includes rules for driving, student-learner exemptions and work hours.



Publicación
F700-167-000
 
Your Daily Record of Hours and Units Worked - For Agricultural Workers / Su registro diario de horas y unidades trabajadas - para trabajadores agrícolas (English/español)

Booklet: A pocket-sized bilingual guide to encourage agricultural workers to keep track of their daily work hours, units and earnings.

Folleto: Una guía de bolsillo bilingüe para animar a los trabajadores agrícolas a mantener un registro de sus horas de trabajo diarias, unidades e ingresos.



Publicación
F700-169-909
 
Farm Labor Contractor Application/Renewal Packet

This is the packet you would complete to register as a farm labor contractor.



Formulario
F700-170-000
 
How To Calculate Your Wage in Agriculture

Fact/Information sheet: Shows piece rate workers how to calculate their wages to check if they are being paid minimum wage.



Publicación
F700-171-000

Otro(s) idioma(s):
Español
 
Cómo calcular su salario en agricultura

Hoja de información: Muestra a los trabajadores por contrato cómo calcular sus salarios y verificar si le están pagando salario mínimo.



Publicación
F700-171-999

Otro(s) idioma(s):
Inglés
 
Farm Internship Project Complaint Form

Complaint form for public to complete and submit



Formulario
F700-172-000
 
Help for Victims of Crime / Ayuda para víctimas de crimen (English/español)

Pamphlet/booklet: Answers questions about Washington State's Crime Victims Compensation Program, who may be eligible for benefits and how to apply.

Folleto: Responde preguntas sobre el Programa de Compensación para Víctimas de Crimen del estado de  Washington, quienes podrían tener derecho a recibir beneficios y cómo pueden aplicar. 

 



Publicación
F800-006-909
 
Statement for Crime Victims Mental Health Services

Used by the Crime Victims Compensation Program providers for reimbursement of Mental Health Services.



Formulario
F800-025-000
 
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
 
Solicitud para reabrir un reclamo debido al empeoramiento de la condición

Los beneficios están limitados a $50,000 por reclamo. Si su reclamo ha llegado o excedido  este límite, su solicitud de reapertura será negada y no podremos pagar beneficios futuros.  Usado por las víctimas de crimen y proveedores médicos o de salud mental para solicitar la reapertura de un reclamo.



Formulario
F800-031-999

Otro(s) idioma(s):
Inglés
 
Help for Crime Victims (large poster)

Poster (11" X 17"): Highlights the Crime Victims Compensation Program and provides contact information. Intended for display in health-care, criminal-justice and social-service organizations. Can be downloaded and printed, or ordered from L&I. Smaller version is also available (8.5" X 11"). Get 11" X 17" poster printing tips.



Cartel
F800-041-000

Otro(s) idioma(s):
Español
 
Ayuda para víctimas de crimen (cartel grande)

Cartel:  Documento con las medidas 11 X 17 pulgadas. Resalta el Programa de Compensación para Víctimas de Crimen y proporciona información para comunicarse con el programa. La intención es ponerlo a la vista en clínicas, organizaciones judiciales y de servicios sociales. Puede descargarse e imprimirse o solicitarse de L&I.  Hay una versión disponible más pequeña (8.5 X 11 pulgadas).



Cartel
F800-041-999

Otro(s) idioma(s):
Inglés
 
Application for Benefits - Crime Victims

This application is used by victims of crime in Washington State to apply for benefits such as compensation for time lost from work; loss of financial support; and medical or mental health treatment.

The application for Homicide Claims is available online by searching for form number F800-120-000.



Formulario
F800-042-000
 
Travel Reimbursement Request - Crime Victims

If you are considered a victim of crime, use this form to track your travel expenses for medical, retraining or vocational services or for an independent medical exam. You should have approval from your claim manager before you travel.



Formulario
F800-049-000
 
Master Level Counselor Provider Account Application for Crime Victims

Master Level Counselor Provider Account Application for Crime Victims



Formulario
F800-053-000
 
Request for Survivor Counseling Benefits / Solicitud para beneficios de apoyo para los sobrevivientes (English/español)  

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
 
Know What to Expect: How Recoveries and Settlements May Impact Your Crime Victim Claim

Pamphlet and form: Explains third-party liability, recoveries and settlements. A crime victim or the Crime Victims Compensation Program may pursue monetary restitution from someone who caused or contributed to a crime victim's injury. Explains the purpose of the form and why individuals who file a crime victims claim are required to complete it.



Publicación
F800-074-000
 
Statement for Crime Victim Miscellaneous Services

Used by the provider or supplier for reimbursement of the following services - dental, glasses, home health, nursing home serivces, medical equipment, prosthetics-orthotics, transportation, vocational, retraining and other.



Formulario
F800-076-000
 
Crime Victims Compensation Program Initial Response and Assessment: Form I
Used by the clinical provider to get approval to see a victim for six sessions or less. If more than six sessions, please complete Form II (F800-081-000).

Formulario
F800-080-000
 
Crime Victims Compensation Program Initial Response and Assessment: Form II

Used by the clinical provider to request authorization to provide more than six sessions. This form must be submitted by the sixth session. (6 pages)



Formulario
F800-081-000
 
Crime Victim Compensation Program Sexual Assault Exam Report

A form used by physicians, hospitals and clinics to provide information and reporting to the Crime Victims Compensation Program.



Formulario
F800-098-000
 
Billing Guidelines for Sexual Assault Examinations: Crime Victims Compensation Program

Provides information health-care providers need to bill the Crime Victims Compensation Program for medical services.



Manual
F800-100-000
 
Helping Providers Understand the Crime Victims Compensation Program
Fact sheet: Answers questions doctors and mental health counselors may have about the Crime Victims Compensation Program and billing for services. Also suggests steps these providers can take to speed up reimbursement.

Publicación
F800-102-000
 
Help for Crime Victims (small poster)

Poster (8.5" X 11"): Highlights the Crime Victims Compensation Program and provides contact information. Intended for display in health-care, criminal-justice, and social-service organizations. Can be downloaded and printed, or ordered from L&I. Larger version is also available (11" X 17").



Cartel
F800-104-000

Otro(s) idioma(s):
Español
 
Mental Health Fee Schedule and Billing Guidelines

Manual: This manual is for providers who bill the Crime Victims Compensation Program for mental health services for crime victims.



Manual
F800-105-000
 
Formulario de verificación de empleo

Para ser utilizado por las víctimas de crimen que están solicitando compensación de reemplazo de salario.



Formulario
F800-110-999

Otro(s) idioma(s):
Inglés
 
Your Independent Medical Exam (IME): Crime Victims Compensation Program
Fact Sheet: Provides answers to commonly asked questions about independent medical exams (IMEs) and contact information. Includes a form for requesting travel-related reimbursement for attending an IME.

Publicación
F800-115-000
 
Crime Victims Direct Entry Billing Manual
Instructions for completing a Direct Entry bill to submit to the Crime Victims Compensation Program. Direct entry allows you to submit or adjust bills using a free online billing form through Provider Express Billing (PEB).

Manual
F800-118-000
 
Crime Victim's Application for Benefits - Homicide Claims

This application is used to apply for benefits such as medical and funeral benefits in the case of homicide.

The application for general Crime Victims Benefits is available online by searching for form number F800-042-000.



Formulario
F800-120-000
 
Ten Safe Handling Hints for Knives
Shows ten tips on handling a knife safely. Get poster printing tips.

Cartel
FSP0-903-000
 
Preventing Slips and Falls
Information on how to prevent slips and falls with your footwear, housekeeping and also some general awareness tips. Get poster printing tips.

Cartel
FSP0-904-000
 
Stay Clear of Suspended Loads
Pictures a guy under a suspended wooden carton. Get poster printing tips.

Cartel
FSP0-908-000
 
Standard Hand Signals for Cranes

Poster: Displays proper hand signals for directing crawler, locomotive and truck crane operators. Please order from L&I or print on 11" X 17" paper.



Cartel
FSP0-910-000
 
Poster - An Unprotected Trench is an Early Grave

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



Cartel
FSP0-912-000
 
The Best Accident Insurance - To observe all safety regulations
Picture of a guy with Saftey Policy and Rules in his hand. Get poster printing tips.

Cartel
FSP0-915-000
 
Four Steps to Proper Lifting
Pictures of a person lifting a large box correctly along with tips on how to correctly lift a large item safely. Get poster printing tips.

Cartel
FSP0-918-000
 
Robos y clientes abusivos: consejos para prevenir lesiones

Consejos sobre cómo manejar el dinero en efectivo y cómo tener un restaurante o un entorno minorista más seguro.  Obtenga información sobre cómo imprimir carteles.



Cartel
FSP0-919-999

Otro(s) idioma(s):
Inglés
 
Caution: Hard Hat Area / Precaución: obligatorio usar un casco (English/español)

Picture of hard hats. Get poster printing tips.

Fotografía de cascos.  Obtenga información sobre cómo imprimir carteles.



Cartel
FSP0-928-999

Otro(s) idioma(s):
Inglés
 
Always Wear Eye Protection
Picture of a large eye with some content on when to use eye protection. Get poster printing tips.

Cartel
FSP0-940-000

Otro(s) idioma(s):
Español
 
Siempre use protección para los ojos (English/español)

Fotografía de un ojo grande con contenido sobre cuando debe usar protección de los ojos. Obtenga información sobre cómo imprimir carteles.



Cartel
FSP0-940-999

Otro(s) idioma(s):
Inglés
 
Always Wear Eye Protection

Sticker: 7.25 inches x 4.25 inches.

This sticker is to remind workers to wear eye protection when grinding, milling, sanding, sawing, welding, chipping, chiseling, etc.



Calcomanía
FSP0-941-000
 
Ladder Safety
Picture of a ladder with safety tips on the rungs. Get poster printing tips.

Cartel
FSP0-951-000
 
Sticker - Danger! Minimum Clearance - Logging

Sticker: 8.25 inches x 6 inches.

This sticker is required for logging. There is a minimum counter balance clearance of 36 inches.



Calcomanía
FSP0-972-000
 
Danger! Minimum Clearance for Counter Balance - Construction

Sticker: 8.25 inches x 6 inches.

This sticker is required for construction. There is a minimum counter balance clearance of 30 inches.



Calcomanía
FSP0-974-000
 
Safe Ways - Fork Lift Safety
Safety tips on using a fork lift. Get poster printing tips.

Cartel
FSP0-978-000
 
Grinding Wheel - Prevent Accidents

Sticker: 4 inches x 3 inches.

This sticker is required for grinder wheel equipment. This sticker reminds workers of the maximum distance between the grinding wheel and tongue guard and the maximum distance between the grinding wheel and the work rest.



Calcomanía
FSP1-000-000
 
Report All Injuries Promptly
Large words: Report All Injuries Promptly. Get poster printing tips.

Cartel
FSP1-004-000

Otro(s) idioma(s):
Español
 
Report All Injuries Promptly / Reporte todas las lesiones inmediatamente (English / español)

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

Palabras en tamaño grande: Reporte todas las lesiones inmediatamente.  Obtenga información sobre cómo imprimir carteles.



Cartel
FSP1-004-999

Otro(s) idioma(s):
Inglés
 
Well...My Daddy Wears 'Em
Little boy wearing his daddy's hard hat, eye protection, gloves and boots. Get poster printing tips.

Cartel
FSP1-010-000
 
Danger, Workers Above / Peligro - Trabajadores en el nivel superior (English/español)

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

Fotografía: Trabajadores en una superficie alta.  Obtenga instrucciones sobre cómo imprimir los carteles.



Cartel
FSP1-012-999

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

Cartel
FSP1-013-000

Otro(s) idioma(s):
Español
 
Peligro - área en construcción - solamente personas authorizadas

En letras grandes: Peligro - área en construcción -  solamente personas autorizadas. Obtenga instrucciones sobre cómo imprimir los carteles.



Cartel
FSP1-013-999

Otro(s) idioma(s):
Inglés
 
Danger / PELIGRO (English/español)

Large lettering: DANGER. Get poster printing tips.

Cartel: En letras grandes: PELIGRO. Obtenga instrucciones sobre cómo imprimir los carteles.



Cartel
FSP1-030-999

Otro(s) idioma(s):
Inglés
 
Walk, Don't Run
Timeless reminder to walk, don't run, showing a banana peel. Get poster printing tips.

Cartel
FSP1-051-000
 
Know Your Lockout Tagout Safety Procedures
Poster: Visual reminder you can print for posting in appropriate workplaces. Two options available for download and/or printing.

Cartel
FSP1-063-000
 
Apprentice Work Progress Record

Worksheets used to record the number of hours worked and Related Supplemental Instruction hours during a registered apprenticeship on a monthly basis. If used, a copy is usually given to the program monthly.



Formulario
F100-002-000
 
On-the-Job Training Agreement Card

This card is used by an OJT Apprenticeship program ONLY. To receive this form, you must contact the Apprenticeship Section.



Formulario
F100-019-000
 
Request for Change of Status - Apprenticeship/Training Agreements and Training Agents

Used to request a change of status for apprentices, the training agreements or the training agents. These are normally accompanied by Committee meeting minutes when submitted.



Formulario
F100-021-000
 
Request for Revision of Committee

Used to request revision of committees to include changing the title of the standards, sub-committee members, and committee members.



Formulario
F100-031-000
 
On-The-Job Training Work Hours

Used to report the work hours for an on-the-job training employee.



Formulario
F100-229-000
 
Authorization of Signature

This gives individuals other than the Secretary or Chairman authorization to sign ALL Papers or just Registration Cards. Must be signed by a quorum of the Apprenticeship Committee.



Formulario
F100-500-000
 
Apprenticeship Transfer Agreement

Used to allow an apprentice to transfer from a Washington State Registered apprenticeship program to another Washington State Registered program.



Formulario
F100-503-000
 
Request for Recognition of Apprenticeship Committee

Used to establish a new apprenticeship committee and list it's employer/employee representatives.



Formulario
F100-504-000
 
Approved Training Agent

Used to allow an employer to train apprentices as part of a Registered Apprenticeship program.



Formulario
F100-508-000
 
Instructor's Report of Accident / Incident

This form must be submitted to L&I's Apprenticeship Section by the Instructor at the time of the incident and the appropriate Apprenticeship Program within 5 days of an accident/incident of an apprentice/trainee during Related Supplemental Instruction (RSI).



Formulario
F100-509-000
 
Notice to Attending Physician of Apprentice / On-the-Job-Training Accident / Incident

A notice to the attending physician that the individual is a Registered Apprentice and to attach this form to the Accident Report of Industry Injury or Occupational Disease (F242-130-000).



Formulario
F100-511-000
 
Notice of Contest or Objection to Proposed Standards of Apprenticeship

Used by competitor to contest or object to a proposed standards of apprenticeship, new occupation or revised geographical area. Submit this form at least 20 days prior to a Council meeting.



Formulario
F100-516-000
 
Apprenticeship Advantage poster
Poster: Introduces apprenticeship, especially for younger people. Promotes the benefits of apprenticeship and includes contact information to learn more.

Cartel
F100-526-000
 
A Parents' Guide to Apprenticeships
Booklet: Designed specifically for parents, this booklet provides an overview of apprenticeship. Topics include the benefits of apprenticeship, career options, requirements, how to apply and contact information.

Publicación
F100-530-000
 
Comparing Career Pathways

Fact sheet: Assists high school students and their parents by comparing the benefits of registered apprenticeship to a traditional university or college program. Compares wages, costs, and length of study.



Publicación
F100-531-000
 
Registered Apprenticeship in the Construction Industry

Brochure: Designed for construction business employers who are interested in hiring apprentices. Includes answers to common questions, how to hire apprentices, the benefits of apprenticeship, testimonials, and contact information.



Publicación
F100-533-000
 
Independent Contractor Guide: A Step-by-Step Guide to Hiring Independent Contractors in Washington State

Pamphlet/booklet: A step-by-step guide to hiring independent contractors in Washington State. This publication is a general guide to help you understand how and when the Department of Labor & Industries applies workers’ compensation laws to independent contractors.



Publicación
F101-063-000

Otro(s) idioma(s):
Español
 
Doing Business with the State of Washington: A Guide to Washington State Bid Opportunities
Pamphlet/booklet: Provides an overview of bid opportunities and processes for Washington State government with specific contact information for the Department of Labor & Industries.

Publicación
F101-087-000
 
Pocket Guide to Worker Rights

Brochure: This guide is to help workers understand their rights in Washington State. It includes information about safety and health protection, minimum wage and overtime pay, prevailing wage, rest and meal breaks, sick leave, family leave, workers' compensation benefits and retaliation.



Publicación
F101-165-000
 
Need a Doctor?

Information card: Provides contact information for injured workers needing assistance in finding a health-care provider who will treat their occupational injury or disease. This PDF will print out an 8.5" X 11" sheet that has 12 copies of the card. Note: Disclaimer information on Page 2 may not line up accurately in two-sided printing.



Publicación
F160-006-000

Otro(s) idioma(s):
Español
 
¿Necesita un doctor?

Tarjeta: Proporciona información a los trabajadores lesionados sobre con quien comunicarse si necesitan ayuda para encontrar un proveedor de cuidado de la salud que pueda darle tratamiento para su lesión o enfermedad ocupacional.  Este documento en formato PDF imprime una hoja de 8.5x11 pulgadas de tamaño carta que tiene 12 copias de la tarjeta.  Aviso: La información del descargo de responsabilidad en la página 2 puede que no esté alineada correctamente con la impresión en ambos lados.



Publicación
F160-006-999

Otro(s) idioma(s):
Inglés
 
Getting Back to Work: It's Your Job and Your Future
Pamphlet/booklet: Briefly explains steps to return to work quickly and minimize the economic impact of time-loss. Also provides helpful resources. Intended for injured workers.

Publicación
F200-001-000

Otro(s) idioma(s):
Español
 
Regresando a trabajar es su trabajo y su futuro

Folleto:  Explica brevemente los pasos para que el trabajor pueda 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
 
On-the-Job Training
Postcard: For employers; summarizes the benefits of providing on-the-job training to an injured worker. The other side is for injured workers who want to return to work; explains how on-the-job training can help them. Includes website address and contact information.

Publicación
F200-021-000
 
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
 
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
 
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
 
Overpayment Reimbursement Fund Request Coversheet

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



Formulario
F207-212-000
 
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
 
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
 
Workers' Compensation Record Keeping and Reporting Guides

Packet: Contains eight quick reference cards covering topics related to workers' compensation record keeping and reporting. Topics include: computering worker hours, standard exception classifications, excluded employments and corporate officers.



Publicación
F212-222-000
 
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 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
 
Temporary Services Guide to Workers' Compensation Insurance

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



Manual
F213-019-000
 
Pre-Audit Questionnaire

Pre-Audit Questionnaire. The fillable MSWord version is saved in the 2003 format. The EXCEL file is saved in ExCEL 2007 format. There is also a fillable PDF version.



Formulario
F213-177-000
 
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
 
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
 
Keys to Retro Success

Fact sheet: Provides information to employers who are considering joining a Retrospective Rating (Retro) group.Contains questions and suggestions to help determine if Retro is right for a business and information regarding annual participation.



Publicación
F225-018-000
 
Inquiry for Assessment of Damages

Your answers to these questions will be used to assist in evaluating your damages if a claim is made against a liable third party.



Formulario
F242-067-000

Otro(s) idioma(s):
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
 
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
 
Insurer 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
 
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
 
Cuestionario para beneficios de pensión

Usado por un trabajador lesionado que recibe una orden estableciendo que él o ella está total y permanentemente discapacitado.  Este cuestionario debe completarse en su totalidad y debe adjuntarse todos los documentos necesarios antes de que pueda calcularse sus opciones de beneficios de pensión.



Formulario
F242-393-999

Otro(s) idioma(s):
Inglés
 
Preauthorization Request for Services for State Fund Workers' Compensation Patients

This form can only be used for services that can be authorized by the claim manager and it should not be used for Utilization Review (Qualis), Provider Hotline or requests to the Occupational Nurse Consultant.  If you are unsure of what services need to be authorized see L&I fee lookup utility at www.Lni.wa.gov/apps/FeeSchedules/

For complete information on all authorization processes please see:  www.Lni.wa.gov/ClaimsIns/Providers/AuthRef/GetAuth.asp



Formulario
F242-397-000
 
Cuestionario de exposición a sustancias químicas

Formulario: Contiene el  Cuestionario de exposición a sustancias químicas F242-409-999, la Autorización para proveer información  F262-005-999 y la versión en inglés solamente de un formulario del Seguro Social que contiene la información apropiada de L&I.



Formulario
F242-409-999

Otro(s) idioma(s):
Inglés
 
Statement for Compound Prescription

Bill form for use by pharmacies and home infusion companies to submit compound drug charges. This form is for drug charges only and is filled out by the pharmacist.



Formulario
F245-010-000
 
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
 
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
 
Interpretive Services Appointment Record (ISAR)

This form is used by interpreters to verify to L&I (state fund and Crime Victims claims) and self-insured employers for interpretive service at medical or vocational visits.

When ordering, there is a limit of 4 pads, or 100 copies total.



Formulario
F245-056-000
 
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
 
Provider's Request for Adjustment

Providers use this to report total overpayment, partial overpayment and/or underpayment by L&I.



Formulario
F245-183-000
 
Su examen médico independiente

Folleto: Respuestas a las preguntas más comunes sobre los exámenes médicos independientes y cuándo y por qué podría requerirse que un trabajador lesionado asistiera a uno.  Incluye el formulario examen médico independiente (IME, por su sigla en inglés) - Solicitud para el reembolso de gastos de viaje y salario. Este formulario es solamente para el uso de negocios autoasegurados y sus trabajadores.



Formulario
F245-224-999

Otro(s) idioma(s):
Inglés
 
UB04 HCFA 1450

Used by hospitals to bill L&I for inpatient/outpatient services. This version includes NPI number.



Formulario
F245-367-000
 
Housing and Board Cost Encumbrance
To record the costs for housing and board. For use only with plans approved after 1/1/2008.

Formulario
F245-372-000
 
Transportation Cost Encumbrance

To record the costs for transportation. For use only with plans approved after 1/1/2008.



Formulario
F245-375-000
 
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
 
HCFA Proprietary Format Companion Guide
This guide details the HCFA proprietary format structure and provides information regarding electronic billing to the department via Provider Express Billing (PEB).

Formulario
F245-394-000
 
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
 
ASC X12N 005010 EDI Transactions Companion Guide
Description: This guide details the HIPAA ASC X12N 005010 format structure for EDI and provides information regarding electronic billing To the department via Provider Express Billing (PEB)

Manual
F245-398-000
 
Pharmacy Companion Guide

This guide details the HIPAA ASC X12N 004010 format structure for 835 Pharmacy Remittance Advice and provides information regarding electronic billing to the department via Provider Express billing (PEB)



Manual
F245-400-000
 
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
 
Quick Reference Card for Providers

Flyer or small poster for administrative staff for health-care and vocational providers: lists the most frequently used procedure codes and fees. The back highlights the most popular or frequently used web pages for providers and their staff. Provides tips for speeding up authorizations and for billing self-insured employers.



Publicación
F245-414-000
 
Statement for Home Nursing Services

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



Formulario
F248-160-000
 
Massage Therapy Treatment Authorization Fax Request

Used by a licensed massage practitioner/clinic to request authorization for outpatient massage therapy services for L&I claims.



Formulario
F248-357-000
 
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
 
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
 
Retrospective Rating Adjustment Protest

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



Formulario
F250-024-000
 
Business and Industry Category Guide

Manual: Provides assistance to retro groups in determining if a prospective employer qualifies for their retrospective rating group program.



Manual
F250-025-000
 
Protesting Retro Adjustments

Fact sheet: Provides important information to employers and Retro groups about the process the department follows when considering an adjustment protest.



Publicación
F250-027-000
 
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
 
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
 
Opioid Treatment Agreement

Use this treatment agreement when starting chronic opioid therapy. It should be renewed yearly or when there is a new prescriber.



Formulario
F252-095-000

Otro(s) idioma(s):
Español
 
Historia de trabajo - pérdida de audición

Hoja de continuación del formulario, Historia de la pérdida de audición.



Formulario
F262-013-999
 
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
 
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
 
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
 
OJT Information Request and Recommendation form

VRCs can use this form to request information on a specific on -the -job (OJT) training opportunity listed on L&I's website, or to recommend an OJT training opportunity.



Formulario
F280-032-000
 
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
 





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