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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

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
F101-010-999

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.

Cartel
F101-054-000
 
Your Privacy Is Important to Us (English/Spanish)
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.

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/Spanish)

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

Panfleto/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 (English/Spanish) - Conozca sus Obligaciones Cuando Miembros de su Familia Trabajan para Usted

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
F101-077-909

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
 
Aplicando para su Licencia de Negocio en Washington: Una Guía Detallada

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
F101-079-999

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
 
Field Operations-Regional Boundaries and Office Information

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
 
L&I 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
 
Protegiendo a los trabajadores de Washington (Protecting Washington Workers)
DVD: An innovative tool to teach Spanish-speaking workers about workplace rights while introducing English terminology.

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
 
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.



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

Instructions for filling out the quarterly statement of supplemental benefits.



Formulario
F207-011-111
 
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

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



Formulario
F207-020-999

Otro(s) idioma(s):
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/Spanish)

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
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

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



Formulario
F207-070-999

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

Pamfleto/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
 
Transfer of Attending Provider Form for Self Insured Workers Spanish Formulario para Trasferencia de Proveedor Principal para Trabajadores Autoasegurados

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

Este 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

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
F207-155-999

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

Schedule of 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 - PPD-TL

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



Formulario
F207-164-999

Otro(s) idioma(s):
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 - PPD-NTL

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



Formulario
F207-165-999

Otro(s) idioma(s):
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
 
Help for Injured Workers of Self-Insured Businesses-Spanish (Ayuda para Trabajadores Lesionados de Empresas Autoaseguradas)

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
F207-201-999

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
 
Your Independent Medical Exam: For Employees of Self-Insured Businesses - Spanish (Su Examen Médico Independiente: Para empleadores de negocios autoasegurados)
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
F207-202-999

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

You must fill out this form quarterly even if you had no workers. These forms are mailed out quarterly to all employers. For instructions on how to complete the Quarterly Report, please refer to F212-239-000 which is available on the internet. This file on the internet is a sample only.



Formulario
F212-055-000
 
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

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
F212-224-999

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
 
Settling your L&I claim might be right for you: A new option for injured workers over 55 - Spanish (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)

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
F240-003-999

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
 
Worker Verification Form - Spanish 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
 
Verification of School Enrollment/Verificación de registro en la escuela (Spanish)

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



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
 
Claim for Pension by Spouse or Children -  Reclamo para Beneficios de Pensión Presentado por el Cónyuge, Pareja Doméstica Registrada o los Hijos (Spanish)

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
F242-056-999

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

Used by dependents of a deceased worker to file a claim for benefits.



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 - Spanish APLICACIÓN PARA REABRIR UN RECLAMO

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.



Formulario
F242-079-909

Otro(s) idioma(s):
Inglés
Español
 
Application to Reopen Claim due to Worsening Condition - Spanish Aplicación para Reabrir un Reclamo Debido al Empeoramiento de la Condición 

Spanish version. 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.



Formulario
F242-079-999

Otro(s) idioma(s):
Inglés
Inglés/Español
 
Beneficios de Compensación para los Trabajadores: Una guía para los Trabajadores Lesionados - English (Workers' Compensation Benefits: A Guide for Injured Workers)

Folleto: Explica los derechos y responsabilidades de los trabajadores bajo la ley de seguro industrial.  Describe beneficios y cómo presentar un reclamo.  Aviso: Anteriormente titulado, Guía de Beneficios del Seguro Industrial para los Trabajadores.  



Publicación
F242-104-999

Otro(s) idioma(s):
Inglés
 
Address Change Request for Pensioners - (Spanish) Solicitud para cambio de dirección para pensionados

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
F242-107-999

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
 
Employment History Form Spanish Formulario de Historial de Empleo

Used by injured worker to report their employment history for the past three years and the wages at each job.



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



Formulario
F242-130-000

Otro(s) idioma(s):
Español
 
Report of Accident Instructions -- Spanish Instrucciones para el Reporte de Accidente

This document provides instructions in Spanish on how to complete the worker portion only of the Report of Accident (ROA). Please note that the Report of Accident is not available in Spanish.



Formulario
F242-130-999
 
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

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
F242-173-911

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

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
F242-173-922

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

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
F242-173-933

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

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
F242-173-944

Otro(s) idioma(s):
Inglés
 
Authorization for Deposit of Payments Spanish Autorización para Depósitos de Pagos (English/Spanish)

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



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/Spanish)

Required poster: Outlines the steps a worker should take if a job-related injury or illness occurs. Also briefly describes the benefits available through Washington's workers' compensation system. Note: 'Employers who receive industrial insurance coverage from L&I must display this poster where workers can see it. English and Spanish online versions will print separately.



Cartel
F242-191-909
 
Application for L.E.P. 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 L.E.P. Compensation Medical (Spanish) Solicitud para Compensación por Reducción de Ingresos (Médicos)

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



Formulario
F242-208-909

Otro(s) idioma(s):
Inglés
Español
 
F242-208-999 Application for LEP compensation medical - Spanish Solicitud para Compensación por Reducción de Ingresos (Médico)

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



Formulario
F242-208-999

Otro(s) idioma(s):
Inglés
Inglés/Español
 
F242-209-000 APPLICATION FOR L.E.P. COMPENSATION VOC
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
 
F242-209-909 Application for LEP Vocational English/Spanish Solicitud para Compensación por Reducción de Ingresos (Vocacional)

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



Formulario
F242-209-909

Otro(s) idioma(s):
Inglés
Español
 
F242-209-999 application for LEP - Voc Spanish -  Aplicación para Compensación por Reducción de Ingresos (Vocacional)

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



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--English/Spanish (Beneficios de Pensión y para Sobrevivientes del Programa de Compensacin para Trabajadores de Washington)

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



Publicación
F242-352-909
 
How to Protest a Department of Labor and Industries Decision (English/Spanish) Cómo Protestar una Decisión en su Reclamo del Departamento de Labor e Industrias

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



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
 
Letter of Intent for School Enrollment - Spanish Carta de Intención de Registro en una Escuela

Letter of Intent for School Enrollment - Spanish CARTA DE INTENCIÓN DE REGISTRO EN UNA ESCUELA



Formulario
F242-382-999

Otro(s) idioma(s):
Inglés
 
Insurer Activity Prescription Form - Spanish Formulario de Restricciones Laborales del Asegurador

Used by Spanish speaking health-care providers to communicate an injured worker's status, physical capacities, inability to work (time-loss) and treatment plans.

Utilizado por proveedores de cuidado de la salud que hablan español para indicar la condición actual del trabajador lesionado, restricciones físicas, certificación de tiempo perdido y planes de tratamiento.



Formulario
F242-385-909

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
 
Address Change Request for Injured Workers - (Spanish) Solicitud para cambio de dirección para trabajadores lesionados

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
F242-388-999

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
 
Application for Pension Benefits by Spouse or Children - (Spanish) Aplicación para Beneficios de Pensión Presentado por el Cónyuge o Hijos

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
F242-391-999

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
 
Affidavit_for_Time_Loss_Compensation_Benefits (Spanish) Declaración Firmada para Compensación de Tiempo Perdido

Affidavit_for_Time_Loss_Compensation_Benefits (Spanish) Declaración Firmada para Compensación de Tiempo Perdido 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 F242-052-999 Worker Verification Form.



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
 
Have you been injured on the job?-Spanish (Se ha lesionado en el trabajo?)

Wallet card: Explains how to file a workers' compensation claim by telephone.



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
 
3 Things to Know About L&I's Medical Provider Network - Spanish (3 Cosas que Debe Conocer Sobre la Red de Proveedores Médicos de L&I)

 

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
F242-406-999

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

Autorization del Trabajador para Obtener Registros de Trabajos Despachados por el Sindicato



Formulario
F242-410-999

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

Pamphlet/booklet: Provides an overview Stay at Work, a financial incentive program that encourages Washington employers to find light-duty or transitional jobs for workers recovering from on-the-job injuries. Includes information on eligibility, how to apply, and where to get more information.



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 de cobro para proveedores que facturan al Departamento por capacitación y servicios de modificación de trabajo.



Formulario
F245-030-999

Otro(s) idioma(s):
Inglés
 
Structural Inspection Request Questionnaire

Structural Inspection Request Questionnaire



Formulario
F622-075-000
 
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
 
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
 
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
 
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
 
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
 
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
 
Approved Independent Medical Examiner (IME) Update
To update or correct the IME's contact, availability, qualificaitons and/or exam sites.

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

Formulario
F245-053-999

Otro(s) idioma(s):
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
 





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