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A Guide to Workers' Compensation Benefits For Employees of Self-Insured Businesses
Publication
F207-085-000

World Language(s):
Español  
Address Change Request for Pensioners
Form
F242-107-000

World Language(s):
Español  
Agreement of Assumption and Guarantee of Workers' Compensation Liabilities (Certified Self-Insurer)
Form
F207-040-001  
Agreement of Assumption and Guarantee of Workers' Compensation Liabilities - Application of Certification
Form
F207-040-000  
Amendment of Irrevocable Standby Letter of Credit
Form
F207-112-111  
Annual Supplemental Surety Information
Form
F207-125-000  
Application for Elective Coverage - Sole Proprietor, Partners, For-Profit Corporate Officers, or Member/Managers of Limited Liability Company (LLC)
Form
F213-042-000  
Application for Exclusion/Inclusion - Mandatory Coverage (Family Farm)
Form
F213-113-000  
Application for Group Retrospective Rating
Form
F250-004-000  
Application for Inclusion on List of Eligible Attorneys
Form
F249-017-000  
Application for Pension Benefits by Spouse or Children
Form
F242-391-000

World Language(s):
Español  
Application for Self-Insurance Certification
Form
F207-001-000  
Application to Reopen Claim due to Worsening Condition / Solictud para volver a abrir un reclamo (English/español)
Form
F242-079-909

World Language(s):
Inglés
Español  
Application to Reopen Claim Due to Worsening Condition
Form
F242-079-000

World Language(s):
English/Español
Español  
Application to Reopen Crime Victim Claim Due to Worsening of Condition
Form
F800-031-000

World Language(s):
Español  
Assessment Eligible Quality Assurance Review Form
Form
F280-008-000  
Authorization for Deposit of Payments
Form
F242-174-000

World Language(s):
English/Español  
Authorization to Release Claim Information
Form
F101-010-000

World Language(s):
Español  
Autorización para proveer información de reclamos
Form
F101-010-999

World Language(s):
Inglés  
Ayuda para trabajadores lesionados de empresas autoaseguradas
Publication
F207-201-999

World Language(s):
Inglés  
Business and Industry Category Guide
Manual
F250-025-000  
Cómo Registrar un Reclamo para la Compensación del Trabajador con Empresas Autoaseguradas
Form
F207-155-999

World Language(s):
Inglés  
Cancellation of Elective Coverage - Sole Proprietors/Partner, Member of Limited Liability Company (LLC), Member of Limited Liability Partnership (LLP) or For-Profit Corporate Officers
Form
F213-004-000  
Cancellation of Elective Coverage for Excluded Employments
Form
F213-005-000  
Certificado de cobertura - ejemplo
Form
F211-141-999

World Language(s):
Inglés  
Certificate of Coverage - SAMPLE ONLY
Form
F211-141-000

World Language(s):
Español  
Challenges and Change: Managing and Innovating through The Great Recession — L&I from 2005-2012
Publication
F101-102-000  
Comentarios Sobre el Exámen Médico Independente
Form
F245-053-999

World Language(s):
Inglés  
Construction Contractor's Application for Workers' Compensation Account with No Workers or Hours
Form
F625-077-000  
Continuación del Historial de Trabajo y de Enfermedad Ocupacional
Form
F242-071-911

World Language(s):
Inglés  
Contract: Report By Contractor - Forest, Range & Timber Industry
Form
F213-011-000  
Contract: Report By Landowner - Forest, Range & Timber Industry
Form
F213-010-000  
Coverage Agreement
Form
F212-044-000  
Crime Victims Provider's Request for Adjustment
Form
F800-064-000  
Cuestionario para beneficios de pensión
Form
F242-393-999

World Language(s):
Inglés  
Cuestionario sobre la pérdida del sentido auditivo en el trabajo
Form
F262-016-999

World Language(s):
Inglés  
Declaración de derechos para dependientes del trabajador fallecido bajo el Programa de Compensación y Beneficios para Trabajadores
Form
F242-173-933

World Language(s):
Inglés  
Declaración de derechos para padres o tutor bajo el Programa de Compensación y Beneficios para Trabajadores
Form
F242-173-922

World Language(s):
Inglés  
Declaración de derechos para viuda(o) bajo el Programa de Compensación y Beneficios para Trabajadores
Form
F242-173-911

World Language(s):
Inglés  
Declaración de derechos para los beneficios de un trabajador totalmente discapacitado bajo las Leyes del Seguro Industrial
Form
F242-173-944

World Language(s):
Inglés  
Declaration of Entitlement for Dependent of Deceased Worker Benefits Under Industrial Insurance
Form
F242-173-333

World Language(s):
Español  
Department of Labor and Industries Home Modification Acknowledgement of Responsibilities
Form
F247-003-000

World Language(s):
Español  
Drywall Contractors
Form
F214-024-000  
Drywall Industry - Owner/Sub-Contractor Report
Form
F212-050-000  
Employers' Guide to Self-Insurance in Washington State
Publication
F207-079-000  
Employers' Guide to Workers' Compensation Insurance in Washington State
Publication
F101-002-000

World Language(s):
Español  
Employment History Form
Form
F242-109-000

World Language(s):
Español  
Formulario de estado de empleo (Formulario de verificación de empleo)
Form
F242-052-999

World Language(s):
Inglés  
Historial de trabajo (enfermedad ocupacional)
Form
F242-071-999

World Language(s):
Inglés
Español  
Irrevocable Standby Letter of Credit
Form
F207-112-000  
Job Analysis Summary
Form
F252-101-000  
Job Analysis
Form
F252-072-000  
Maritime Coverage
Form
F212-034-000  
Maritime Coverage
Publication
F212-034-000  
Mechanized Logging Supplemental Quarterly Report
Form
F212-223-000  
Memorandum of Understanding Irrevocable Standby Letter of Credit
Form
F207-113-000  
Memorandum of Understanding
Form
F207-129-000  
Non-accredited or Unlicensed Training Provider Application Supplemental Requirements
Form
F280-045-000  
Notice of Occupational Disease or Infection
Form
F242-243-000  
Notificación de decisión de cierre con discapacidad parcial permanente para empleadores autoasegurados - DISCAPACIDAD PARCIAL PERMANENTE (PPD) - SIN TIEMPO PERDIDO (NTL)
Form
F207-165-999

World Language(s):
Inglés  
Notificación de decisión de cierre con discapacidad parcial permanente para empleadores autoasegurados -DISCAPACIDAD PARCIAL PERMANENTE (PPD) - CON TIEMPO PERDIDO (NTL)
Form
F207-164-999

World Language(s):
Inglés  
Notificación de decisión de cierre para reclamos únicamente médicos para empleadores autoasegurados
Form
F207-020-999

World Language(s):
Inglés  
Notificación de decisión de cierre para reclamos de tiempo perdido para empleadores autoasegurados
Form
F207-070-999

World Language(s):
Inglés  
Occupational Disease & Employment History
Form
F242-071-000

World Language(s):
Español  
Occupational Disease Employment History Hearing Loss
Form
F262-013-000

World Language(s):
Español  
Occupational Disease Work History - Continuation
Form
F242-071-111

World Language(s):
Español  
Occupational Hearing Loss Questionnaire
Form
F262-016-000

World Language(s):
Español  
Payroll Service Provider - Quarterly Reporting Bulk Filing Enrollment Form
Form
F248-343-000  
Pension Benefits Questionnaire
Form
F242-393-000

World Language(s):
Español  
Performance Based Physical Capacities Evaluation
Form
F245-023-000  
Plan Development Quality Assurance Review Form
Form
F280-007-000  
Plan Room and Board Cost Encumbrance
Form
F245-372-000  
Preferred Worker Status Request
Form
F280-023-000  
Preparing for Your Self-Insurance Audit
Publication
F207-110-000  
Provider's Initial Report (PIR)
Form
F207-028-000  
Quarterly Report for Self-Insured Business
Form
F207-006-000  
Quarterly Reporting for Drywall
Form
F212-224-000

World Language(s):
Español  
Quarterly Statement of Supplemental Benefits Paid for Self-Insured Employers
Form
F207-011-000  
QuickFile: Workers' Compensation Quarterly Report Filing Made Easy!
Publication
F212-244-000  
Reclamo para beneficios de pensión presentado por los dependientes
Form
F242-062-999

World Language(s):
Inglés  
Reclamo para beneficios de pensión presentado por el cónyuge, pareja doméstica registrada o los hijos
Form
F242-056-999

World Language(s):
Inglés  
Reforestation Contract Supplemental Report - Forest, Range and Timber Industry
Form
F213-013-000  
Reforestation Industry Continuation Sheet (Over $10,000)
Form
F213-015-000  
Report of Accident (ROA) Workplace Injury, Accident or Occupational Disease
Form
F242-130-000

World Language(s):
Español  
Reporte trimestral para la industria de tabla de yeso
Form
F212-224-999

World Language(s):
Inglés  
Request for Claim Information
Form
F101-010-111  
Request for Survivor Counseling Benefits / Solicitud para beneficios de apoyo para los sobrevivientes (English/español)  
Form
F800-057-909  
Self Insurance Continuing Education Report of Course Completion
Form
F207-191-000  
Self Insurance Continuing Education Sponsor/Instructor Application for Course Approval
Form
F207-192-000  
Self-Insurance Certification Questionnaire
Form
F207-176-000  
Self-Insurance Electronic Data Reporting System (SIEDRS): Enrollment Package 2.0
Publication
F207-194-000  
Self-Insurance Report of Occupational Injury or Disease (SIF-5)
Form
F207-005-000  
Self-Insurance Vocational Reporting Form
Form
F207-190-000  
Self-Insured Employer Certificate of Excess Insurance
Form
F207-095-000  
Self-Insured Employers' Medical Only Claim Closure Order and Notice
Form
F207-020-111

World Language(s):
Español  
Self-Insured Employers' Permanent Partial Disability Closure Order and Notice - PPD-NTL
Form
F207-165-000

World Language(s):
Español  
Self-Insured Employers' Permanent Partial Disability Closure Order and Notice - PPD-TL
Form
F207-164-000

World Language(s):
Español  
Self-Insured Employers' Time Loss Claim Closure Order and Notice
Form
F207-070-000

World Language(s):
Español  
Self-Insurer Accident Report (SIF-2)
Form
F207-002-000  
Self-Insurer's Pension Bond
Form
F207-065-000  
SIEDRS (Self-Insurance Electronic Data Reporting System) Data Change Request
Form
F207-197-000  
SIF-5A Cover Sheet: Wage Calculations
Form
F207-156-000  
Solicitud para beneficios de pensión presentado por el cónyuge o los hijos
Form
F242-391-999

World Language(s):
Inglés  
Solicitud para cambio de dirección para pensionados
Form
F242-107-999

World Language(s):
Inglés  
Solicitud para cambio de dirección para trabajadores lesionados
Form
F242-388-999

World Language(s):
Inglés  
Solicitud para reabrir un reclamo debido al empeoramiento de la condición 
Form
F242-079-999

World Language(s):
Inglés
English/Español  
Solicitud para reabrir un reclamo debido al empeoramiento de la condición
Form
F800-031-999

World Language(s):
Inglés  
Sports Player Coverage Agreement
Form
F212-242-000  
Sports Teams Coverage Agreement
Form
F212-196-000  
Statement for Crime Victim Miscellaneous Services
Form
F800-076-000  
Statement for Miscellaneous Services
Form
F245-072-000

World Language(s):
Español  
Statewide Payee Registration and W-9 Form Crime Victims
Form
F800-065-000  
Student Volunteers and Workers' Compensation Coverage
Publication
F213-023-000  
Su examen médico independiente: para empleadores de negocios autoasegurados
Publication
F207-202-999

World Language(s):
Inglés  
Supplemental Quarterly Report for the Drywall Industry
Form
F212-051-000  
Tarjeta para transferencia de caso
Form
F245-037-999

World Language(s):
Inglés  
Temporary Services Guide to Workers' Compensation Insurance
Manual
F213-019-000  
Third Party Recovery Worksheet
Form
F249-006-111  
Time Encumbrance Form
Form
F245-376-000  
Training Plan Cost Encumbrance
Form
F245-374-000  
Transfer of Care Card
Form
F245-037-000

World Language(s):
Español  
Transportation Cost Encumbrance
Form
F245-375-000  
Work Status Form (formerly Worker Verification Form)
Form
F242-052-000

World Language(s):
Español  
Worker Request for Union Dispatch Records
Form
F242-410-000

World Language(s):
Español  
Workers' Compensation Discrimination / Discriminación porque se lesionó en su trabajo (English/español)
Publication
F262-249-909  
Workers' Compensation Employer's Quarterly Report
Form
F212-055-000  
Workers' Compensation Filing Information
Form
F207-155-000

World Language(s):
Español  
Workers' Compensation Record Keeping and Reporting Guides
Publication
F212-222-000  
Your Premium Dollars at Work (2013)
Publication
F200-022-000  
Your Workers' Compensation Rate Notice - SAMPLE ONLY
Form
F225-004-000  
Acknowledgement of Security Interest
Form
F207-143-000  
Address Change Request for Injured Workers
Form
F242-388-000

World Language(s):
Español  
Application for Group Membership & Authorization for Release of Insurance Data
Form
F250-016-000  
Assignment of Account Agreement
Form
F207-058-000  
Audit Reference Card
Publication
F214-020-000  
Claim for Pension By Dependents
Form
F242-062-000

World Language(s):
Español  
Claim for Pension by Spouse or Children
Form
F242-056-000

World Language(s):
Español  
Computing Worker Hours
Publication
F214-014-000  
Declaration of Entitlement for Guardian Benefits under Industrial Insurance
Form
F242-173-222

World Language(s):
Español  
Declaration of Entitlement for Totally Disabled Worker Benefits Under Industrial Insurance
Form
F242-173-444

World Language(s):
Español  
Declaration of Entitlement for Widow or Widower Benefits Under Industrial Insurance
Form
F242-173-111

World Language(s):
Español  
Excluded and Exempt Employments
Publication
F214-013-000  
Five Steps to File
Publication
F212-243-000  
Independent Contractors
Publication
F214-012-000  
Independent Medical Exam Comments
Form
F245-053-000

World Language(s):
Español  
Individual Retrospective Rating Plan Agreement
Form
F250-003-000  
Intent to Hire Preferred Worker
Form
F280-010-000  
Intent to Hire Preferred Worker with Developmental Disabilities
Form
F280-011-000  
Letter of Intent for School Enrollment
Form
F242-382-000

World Language(s):
Español  
Limited Liability Companies (LLC)
Publication
F214-021-000  
Pension Bond Rider
Form
F207-120-000  
Preferred Worker Employers Job Decsription
Form
F280-022-000  
Record Keeping
Publication
F214-011-000  
Self-Insurance Electronic Data Reporting System (SIEDRS) Enrollment Form
Form
F207-193-000  
Self-Insurance Vocational Services Closing Cover Sheet
Form
F207-171-000  
Self-Insurer's Bond - Existing Liabilities
Form
F207-068-000  
SIF-4 Self Insured Employer's Request for Denial of Claim
Form
F207-163-000  
Special Escrow Account - Amendment Agreement
Form
F207-137-000  
Special Escrow Agreement
Form
F207-039-000  
Surety Rider
Form
F207-134-000  
The ABCs of Classifications in Washington
Publication
F213-022-000  
Verification of School Enrollment
Form
F242-055-000

World Language(s):
Español  
Your Independent Medical Exam: For Employees of Self-Insured Businesses
Publication
F207-202-000

World Language(s):
Español  
Your Premium Dollars at Work (2015)
Publication
F200-025-000  





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