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Number Title
BLSF-700-028

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.

F100-002-000 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.

F100-012-000

Program Equal Employment Opportunity Activity Documentation


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

F100-016-000

Apprenticeship Agreement


Used by the registered apprenticeship program to setup an agreement with the apprentice.

F100-019-000

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.

F100-021-000

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.

F100-022-000 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.
F100-030-000 Request for Revision of Standards
Used to request a revision of standards except for committee members.
F100-031-000

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.

F100-033-000

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.

F100-041-000 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.
F100-045-000 Apprenticeship Applicant Register
Example: Used for tracking applicants for an apprenticeship program. Registered Apprenticeship Programs use their own forms.
F100-049-000 Request for Approval of Proposed Standards
Request for new apprenticeship standards.
F100-050-000

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.

F100-228-000

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.

F100-229-000

On-The-Job Training Work Hours


Used to report the work hours for an on-the-job training employee.

F100-303-000 Request for Cancellation of Program
Used for cancelling an apprenticeship program.
F100-500-000

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.

F100-503-000

Apprenticeship Transfer Agreement


Used to allow an apprentice to transfer from a Washington State Registered apprenticeship program to another Washington State Registered program.

F100-504-000

Request for Recognition of Apprenticeship Committee


Used to establish a new apprenticeship committee and list it's employer/employee representatives.

F100-505-000

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.

F100-508-000

Approved Training Agent


Used to allow an employer to train apprentices as part of a Registered Apprenticeship program.

F100-509-000

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).

F100-510-000 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
F100-511-000

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).

F100-512-000

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.

F100-513-000

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.

F100-515-000

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)

F100-516-000

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.

F100-518-000

Related Supplemental Instruction / On-the-Job Training Hours


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

F100-519-000 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.
F100-520-000

Apprenticeship Related Supplemental Instruction (RSI) Plan Review


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

F100-521-000 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.
F100-523-000

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.

F100-526-000 Apprenticeship Advantage poster
Poster: Introduces apprenticeship, especially for younger people. Promotes the benefits of apprenticeship and includes contact information to learn more.
F100-528-000

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.

F100-529-000 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.
F100-530-000 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.
F100-531-000 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.

F100-532-000

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.

 

F100-533-000

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.

F100-535-000

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).

F101-002-000

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.

F101-009-000

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.

F101-010-000

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.

F101-010-111

Request for Claim Information


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

F101-010-999

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.

F101-054-000 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.
F101-055-909

Your Privacy Is Important to Us / Su privacidad es importante para nosotros (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.

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.  

F101-061-404 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.
F101-061-505 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.
F101-061-606 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.
F101-061-707 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.
F101-061-909

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. 

F101-063-000

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.

F101-063-999

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.

F101-068-000

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.

F101-077-303

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.

F101-077-404 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.
F101-077-505 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.
F101-077-707 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.
F101-077-808 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
F101-077-909

If Family Members Work for You, Know Your Obligations / Conozca sus Obligaciones Cuando Miembros de su Familia Trabajan para Usted (English/Spanish)


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.

F101-078-000 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.
F101-079-000 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.
F101-079-999

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


Panfleto: Breve, panfleto 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.

F101-080-000

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.

F101-086-000

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.

F101-087-000 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.
F101-088-000 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.
F101-089-000

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.

F101-091-000 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.
F101-091-034

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.

F101-095-000 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.
F101-099-000 Strategic Plan
Booklet: Explains the strategic direction of the Department of Labor & Industries. Includes a message from the director, goals, objectives and strategies.
F101-100-000

Office Locations


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.

F101-101-000

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.

F101-102-000

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.

F101-165-000 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.

F120-097-000 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)
F120-116-000

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)

F130-004-909

Protecting Washington Workers / Protegiendo a los trabajadores de Washington (English/Spanish)


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.

F160-006-000

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.

F160-006-999

Necesita un doctor?


Tarjeta de información: 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 PDF imprime una hoja “8.5x11” 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.

F200-001-000 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.
F200-001-999

Regresando a Trabajar es su Trabajo y su Futuro


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

 

 

F200-002-000 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.
F200-003-000 Employer's Return-to-Work Guide

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

F200-019-000

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.

F200-020-000

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.

F200-021-000 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.
F200-022-000

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.

F207-001-000

Application for Self-Insurance Certification


Used by employers to apply for self-insurance certification.

F207-002-000

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.

F207-005-000

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.

F207-006-000

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.

F207-011-000

Quarterly Statement of Supplemental Benefits Paid for Self-Insured Employers


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

F207-011-111

Quarterly Statement of Supplemental Benefits Instructions


Instructions for filling out the quarterly statement of supplemental benefits.

F207-020-111

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.

F207-020-999

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.

F207-028-000

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.

F207-037-909

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 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.

F207-039-000 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.
F207-040-000

Agreement of Assumption and Guarantee of Workers' Compensation Liabilities - Application of Certification


Used by an employer to apply for self-insurance.

F207-040-001

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.

F207-058-000 Assignment of Account Agreement
Used by a self-insured employer as an option to provide collateral for a total permanent disability claim.
F207-065-000

Self-Insurer's Pension Bond


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

F207-068-000 Self-Insurer's Bond - Existing Liabilities
Used to provide collateral for a self-insured program.
F207-070-000

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.

F207-070-999

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.

F207-079-000 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.
F207-085-000

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.

F207-085-999

Guía de Beneficios de Compensación para los Trabajadores: Para los Empleados de Empresas Autoaseguradas


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.

F207-095-000

Self-Insured Employer Certificate of Excess Insurance


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

F207-110-000

Preparing for Your Self-Insurance Audit


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

F207-112-000

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.

F207-112-111

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.

F207-113-000

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.

F207-114-000

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.

F207-114-999

Formulario para Trasferencia de Proveedor Principal para Trabajadores Autoasegurados


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.

F207-120-000 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.
F207-125-000

Annual Supplemental Surety Information


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

F207-129-000

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.

F207-134-000 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.
F207-137-000 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.
F207-143-000 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.
F207-155-000

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.

F207-155-999

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.

F207-156-000

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.

F207-162-000

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.

F207-163-000 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.
F207-164-000

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.

F207-164-999

Notificación de Decisión de Cierre con Discapacidad Parcial Permanente para Empleadores Autoasegurados - PPD-TL


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.

F207-165-000

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.

F207-165-999

Notificación de Decisión de Cierre con Discapacidad Parcial Permanente para Empleadores Autoasegurados - PPD-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.

F207-171-000 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.
F207-176-000

Self-Insurance Certification Questionnaire


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

F207-190-000

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).

F207-191-000

Self Insurance Continuing Education Report of Course Completion


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

F207-192-000

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.

F207-193-000 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.
F207-194-000

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.

F207-197-000

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

F207-201-000 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.
F207-201-999

Ayuda para Trabajadores Lesionados de Empresas Autoaseguradas


Tarjeta de información:  Hace una introducción de la Oficina del (Defensor) Ombudsman 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.

F207-202-000 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.
F207-202-999

Su Examen Médico Independiente: Para empleadores de negocios autoasegurados


Panfleto: 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) Solicitud para el reembolso de gastos de viaje y salario." Esta publicación es para uso solamente de las empresas autoaseguradas y sus trabajadores.

F207-206-000

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.

F207-207-000

Self-Insurance Medical Provider Billing Dispute form


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

F207-212-000

Overpayment Reimbursement Fund Request Coversheet


This form is a coversheet used by Self-Insurance for overpayment reimbursement fund requests.

F211-141-000

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.

F211-141-999

Certificado de Cobertura - Ejemplo


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

F212-034-000

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.

F212-044-000

Coverage Agreement


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

F212-050-000

Drywall Industry - Owner/Sub-Contractor Report


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

F212-051-000

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).

F212-055-000

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.

F212-196-000

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.

F212-222-000

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.

F212-223-000

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.

F212-224-000

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.

F212-224-999

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 F212-050-000 y el F212-051-000.

F212-233-000 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).
F212-234-000

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.

F212-239-000

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.

F212-242-000

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.

F212-243-000 Five Steps to File
Flyer: Reviews the steps for filing workers' compensation quarterly reports online and lists the filing due dates.
F212-244-000

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.

F212-245-000 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.
F212-246-000

Monthly Supplemental Report for Manual Logging


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

F213-004-000

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.

F213-005-000

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.

F213-008-000

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.

F213-010-000

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.

F213-011-000

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.

F213-013-000

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).

F213-015-000

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.

F213-019-000

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.

F213-022-000 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.
F213-023-000

Student Volunteers and Workers' Compensation Coverage


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

F213-042-000

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.

F213-112-000

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.

F213-113-000

Application for Exclusion/Inclusion - Mandatory Coverage (Family Farm)


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

F213-177-000

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.

F213-178-000

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.

F214-010-000 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.

F214-011-000 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.

F214-012-000 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.

F214-013-000 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.

F214-014-000 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.

F214-016-000 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.

F214-020-000 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.
F214-021-000 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.

F214-024-000

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.

F215-038-000

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.

F215-039-000

Financial Statement Sole Proprietors and Individuals


Requesting Financial Information for Sole Proprietors and/or Individuals.

F215-040-000

Financial Statement Businesses


Requesting Financial Information for Corporations, LLC and Partnerships.

F225-004-000

Your Workers' Compensation Rate Notice - SAMPLE ONLY


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

F225-016-000 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.
F225-017-000 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.
F225-018-000 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.

F225-019-000

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.

F240-003-000

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.

F240-003-999

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/Spanish)


Panfleto/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.

F240-004-000

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.

F240-007-000

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.

F241-021-000

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.

F242-052-000

Worker Verification Form


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

 

F242-052-999

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.  

F242-055-000 Verification of School Enrollment

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

F242-055-999

Verificación de registro en la escuela


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

F242-056-000 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.
F242-056-999

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.

F242-062-000 Claim for Pension By Dependents
Used by dependents of a deceased worker to file a claim for benefits.
F242-062-999

Reclamo para Beneficios de Pensión Presentado por los Dependientes


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

F242-067-000

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.

F242-067-999

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.

F242-071-000

Occupational Disease & Employment History


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

F242-071-111

Occupational Disease Work History - Continuation


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

F242-071-911

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.

F242-071-999

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.

F242-079-000

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.

F242-079-909

Application to Reopen Claim due to Worsening Condition / Aplicación para Reabrir un Reclamo (English/Spanish)


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.

F242-079-999

Aplicación para Reabrir un Reclamo Debido al Empeoramiento de la Condición 


Versión en español.  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.

F242-104-000

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.

F242-104-999

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: Anteriormente titulado, Guía de Beneficios del Seguro Industrial para los Trabajadores.  

F242-107-000

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.

F242-107-999

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.

F242-109-000

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?

F242-109-999

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

F242-130-000

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.

F242-130-999

Instrucciones para el Reporte de Accidente


Este documento proporciona instrucciones en español sobre como completar solamente la porción del trabajador en el Reporte de accidente (ROA, por su sigla en inglés).  Por favor note que el Reporte de Accidente no está disponible en español.

F242-138-111

Chapter 51.24 RCW Actions at Law for Injury or Death


Distribution of Amount Recovered—Lien (RCW 51.24.060).  Update to 2001 Publication – RCW 51.24.060(6)(7).  The PDF is 8 1/2" x 14" if you print a copy.

F242-138-999

Chapter 51.24 RCW Actions at Law for Injury or Death - Spanish Capítulo 51.24 Acciones Legales por Lesiones o Fallecimiento


Actualización de la Publicación de 2001 – Código Revisado de Washington (RCW, por su sigla en inglés) 51.24.060(6)(7).  Esta actualización cambia el requisito de entrega por correo registrado o certificado por ‘entrega por un método cuya recepción puede ser confirmada o localizada.'

 

 

F242-173-111 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.
F242-173-222 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.
F242-173-333 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.
F242-173-444 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.
F242-173-911

Declaración de Derechos para Viuda(o) bajo el Programa de Compensación y Beneficios para Trabajadores


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

F242-173-922

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.

F242-173-933

Declaración de Derechos para Dependiente del Trabajador Fallecido Bajo el Programa de Compensación y Beneficios para Trabajadores


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

F242-173-944

Declaración de Derechos para los Beneficios de un Trabajador Totalmente Discapacitado Bajo las Leyes del Seguro Industrial


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

F242-174-000

Authorization for Deposit of Payments


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

F242-174-909

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


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

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

F242-191-909

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


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

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

F242-208-000

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.

F242-208-909

Application for LEP 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.

Este formulario completo no es una garantía para recibir beneficios.  Los pagos de beneficios lo decidirá su gerente de reclamo.

F242-208-999

Solicitud para Compensación por Reducción de Ingresos (Médico)


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

F242-209-000

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.

F242-209-909

Application for LEP Vocational / Solicitud para Compensación por Reducción de Ingresos (Vocacional) (English/Spanish)


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

Este formulario completo no es una garantía para recibir beneficios.  Los pagos de beneficios lo decidirá su gerente de reclamo.

F242-209-999

Aplicación 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.

F242-243-000

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.

F242-352-909

Pension and Survivor Benefits in Washington State's Workers' Compensation Program / Beneficios de Pensión y para Sobrevivientes del Programa de Compensacin para Trabajadores de Washington (English/Spanish)


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

Panfleto/folleto: Respuestas para las preguntas más comunes sobre pensión y beneficios para sobrevivientes bajo el programa de compensación para los trabajadores de Washington.

F242-363-909

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


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.

F242-382-000 Letter of Intent for School Enrollment
Use by a full-time student who is entitled to receive pension benefits. The student must be at least 18 years old and no older than 23 years old. This form is to prove the students intention to register in an accredited school during the next quarter/semester.
F242-382-999

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.

F242-385-000

Insurer Activity Prescription Form


Used by health-care providers to communicate an injured worker's status, physical capacities, inability to work (time-loss) and treatment plans. To print an APF, click on the title of the form in the box above.

F242-385-909

Insurer Activity Prescription Form / Formulario de Restricciones Laborales del Asegurador (English/Spanish)


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.

F242-387-000

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.

F242-388-000 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.
F242-388-999

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.

F242-391-000

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.

F242-391-999

Aplicación para Beneficios de Pensión Presentado por el Cónyuge o Hijos


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.

F242-393-000

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.

F242-393-999

Cuestionario para Beneficios de Pensión


Usado por un trabajador lesionado que recibe una orden estableciendo que el o ella está total y permanentemente discapacitado.  Este cuestionario debe completarse en su totalidad y deben adjuntarse todos los documentos necesarios antes de que puedan calcularse sus opciones de beneficios de pensión.

F242-395-000

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.

F242-395-999

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.

F242-397-000

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

F242-398-000 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.
F242-399-000 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.
F242-400-000 FileFast wallet card for workers
Wallet card (3.5 x 2): Reminds workers of FileFast web address and number for call center.
F242-404-999

Se ha lesionado en el trabajo?


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

F242-406-000

3 Things to Know about L&I's Medical Provider Network


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

F242-406-999

3 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. La volante la pueden utilizar los trabajadores cubiertos por L&I y por las empresas autoaseguradas.  Se aplica a los trabajadores en el estado de Washington.  Incluye información para comunicarse por la Internet y el número de teléfono.  

F242-409-000

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.

F242-409-999

Cuestionario de Exposición a Sustancias Químicas


El 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.

F242-410-000

Worker Request for Union Dispatch Records


Worker Request for Union Dispatch Records

F242-410-999

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


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

F243-001-000

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.

F243-003-000

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.

F243-005-000

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.

F243-006-000

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.

F243-006-999

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


Panfleto/folleto: Proporciona un resumen del programa Permanezca en el trabajo, un programa con un incentivo económico que exhorta 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.

F245-010-000

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.

F245-023-000

Performance Based Physical Capacities Evaluation


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

F245-030-000

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.

F245-030-999

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.

F245-037-000

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

F245-037-999

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.

F245-043-000

REFUND NOTIFICATION Refunding Money to L&I to correct your account?


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

F245-046-000

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.

F245-047-000

Independent Medical Examination (IME) Provider Exam Sites


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

F245-049-000

Hearing Services Worker Information


This is a list of the rights and conditions when an injured worker applies for hearing aids.

F245-050-000 Termination of Agreement (Rescission)
To be filled out by the injured worker who wants to return hearing aids.
F245-051-000 Approved Independent Medical Examiner (IME) Update
To update or correct the IME's contact, availability, qualificaitons and/or exam sites.
F245-053-000 Independent Medical Exam Comments
Used by the injured worker to provide comments to L&I about their recent medical exam by an IME.
F245-053-999

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).

F245-055-000

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.

F245-056-000

Interpretive Services Appointment Record


This form is used when an interpreter is appointed to interpret for an injured worker during their medical visits.

When ordering, there is a limit of 4 pads, or 100 copies total. Fax your request to the L&I Warehouse at 360-902-4525 or email whsemail@Lni.wa.gov   Include the following in your request: Your name, mailing address, and telephone number and form number F245-056-000.

F245-057-000 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.
F245-058-000 Independent Medical Exam Template
Template used by a doctor during an independent medical exam.
F245-059-000

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.

F245-072-000

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].

 

F245-072-999

Declaración para Servicios Misceláneos


Este 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.

F245-100-000

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.

F245-127-000 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.
F245-145-000

Travel Reimbursement Request


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

F245-145-999

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.

F245-183-000

Provider's Request for Adjustment


Providers use this to report total overpayment, partial overpayment and/or underpayment by L&I.

F245-224-000

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.

F245-224-999

Su Examen Médico Independiente


Panfleto/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) - Solicitud para el reembolso de gastos de viaje y salario.” Este formulario es solamente para el uso de negocios autoasegurados y sus trabajadores.

F245-340-000

Labor and Industries Prosthetic Device Request Form


Labor and Industries Prosthetic Device Request

F245-346-000

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.

F245-346-999

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.  

F245-350-000

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.

F245-350-999

Adaptacion Previa al Trabajo Solicitudad de Ayuda


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.



F245-351-000

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.

F245-351-999

Acuerdo de propiedad de Herramientas y Equipo para el Plan de Formacion Profesional


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.

F245-365-000

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.

F245-367-000

UB04 HCFA 1450


Used by hospitals to bill L&I for inpatient/outpatient services. This version includes NPI number.

F245-372-000 Housing and Board Cost Encumbrance
To record the costs for housing and board. For use only with plans approved after 1/1/2008.
F245-374-000

Training Plan Cost Encumbrance


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

F245-375-000

Transportation Cost Encumbrance


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

F245-376-000 Plan Time Encumbrance
To record the work plan time. For use only with plans approved after 1/1/2008.
F245-377-000

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.

F245-382-000 Notice of Independent Medical Exam No-Show or Late Cancellation
Notice of Independent Medical Exam No-Show or Late Cancellation
F245-383-000 Independent Medical Examination Fax Cover Sheet
Independent Medical Examination Fax Cover Sheet
F245-384-000

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.

F245-392-000 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.
F245-393-000 L&I Chiropractic Consultant Application
This application is for doctors applying for second opinion examiner (consultant) status. Current consultants do not need to reapply.
F245-394-000 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).
F245-397-000 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.
F245-398-000 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)
F245-400-000 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)
F245-411-000

Washington Practitioner Application


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

F245-412-000 Interpreter Services for Injured Workers and Crime

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.

F245-412-999

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.

F245-414-000

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.

F247-003-000

Department of Labor and Industries Home Modification Acknowledgement of Responsibilities


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

F247-003-999

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

F248-011-000

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

F248-031-000

Electronic Billing Authorization


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

F248-036-000

Statewide Payee Registration and W-9 Form


Use this form to register or update your taxpayer ID number or register and make changes to your direct deposit information.

F248-040-000 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.
F248-055-000

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.

F248-100-000

General Provider Billing Manual


General billing information for those providers that bill the department.

F248-160-000

Statement for Home Nursing Services


Used to bill L&I for reimbursement of home nursing services.

F248-343-000

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.

F248-355-000 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).
F248-357-000

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.

F248-361-000

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.

F248-361-999

Solicitud de Cuenta para Proveedores Fuera del País


Esta solicitud es para proveedores 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.

F248-366-000 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.

F249-006-111

Third Party Recovery Worksheet


Used by third party attorneys to calculate distribution of proposed settlements in third party claims.

F249-008-000

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.

F249-008-999

¿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.

 

F249-017-000 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.
F249-021-000 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.
F250-003-000 Individual Retrospective Rating Plan Agreement
Used by employers to set up an agreement between them and L&I authorizing their participation in retrospective rating.
F250-004-000

Application for Group Retrospective Rating


Used by organizations to set up an agreement with L&I authorizing their participation in retrospective rating.

F250-006-000 Is Retrospective Rating Right for You?
Pamphlet: Provides information about L&I's Retrospective Rating Program. In Retro, employers can earn a partial refund of workers' compensation premiums if they reduce workplace injuries and lower associated claim costs.
F250-016-000 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.
F250-024-000

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.

F250-025-000

Business and Industry Category Guide


Manual: Provides assistance to retro groups in determining if a prospective employer qualifies for their retrospective rating group program.

F250-026-000

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.

F250-027-000

Protesting Retro Adjustments


Fact sheet: Provides important information to employers and Retro groups about the process the department follows when considering an adjustment protest.

F252-001-000

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.

F252-004-000

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.

F252-006-000 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.
F252-007-000 Hearing Impairment Calculation Worksheet
Used by the attending doctor to determine hearing loss.
F252-013-000

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.

F252-021-000

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.

F252-022-000

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.

F252-027-000

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.

F252-028-000

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.

F252-029-000

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.

F252-030-000

Intern Supplemental Application


Intern Supplemental Application

F252-032-000

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.

F252-040-000

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.

F252-051-000

Sample Format for Vocational Testing Report


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

F252-052-000

Sample Format for Vocational Evaluation Testing Plan


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

F252-056-000 Doctor's Worksheet for Rating Cervical and Cervico-Dorsal Impairment
Doctor's Worksheet for Rating Cervical and Cervico-Dorsal Impairment
F252-060-000 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.

F252-060-999

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.

F252-061-000

Home Modification for Workers with Catastrophic Injuries - Questions and Answers for Contractors


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

F252-061-999

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.

F252-072-000

Job Analysis


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

F252-081-000 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.
F252-081-999

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.

F252-088-000

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.

F252-091-000

Chronic Opioid Request Form


Use this form to request opioid coverage beyond 12 weeks from the date of injury or surgery, or every 90 days for chronic opioid therapy.

F252-094-000

L&I Benefits for Workers Who Are Terminally Ill


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

F252-095-000

Opioid Treatment Agreement


Use this treatment agreement when starting chronic opioid therapy. It should be renewed yearly or when there is a new prescriber.

F252-095-999

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.

F252-097-000

Subacute Opioid Request Form


Use this form to request opioid coverage between 6 weeks to 12 weeks from the date of injury or surgery.

F252-098-000

Attending Provider's Referral Form


Attending Providers send this form to refer injured workers for medical opinion consultations, specialty/surgical consultations, concurrent care (authorization required), transfer of care consultation, or closing exam and impairment rating. Give a copy of the completed form to the injured worker.

F252-099-000

PT/OT Referral Form


Attending Providers use this form to refer injured workers for physical or occupational therapy to progressively increase activity and exercise, or activity tolerance, develop home or self-care programs, and perform work activity conditioning. Explains to therapists your specific requests and expected follow-up therapy reports.

F252-101-000

Job Analysis Summary


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

F262-009-000

Industrial Insurance Discrimination Complaint


Employees who believe they have been discriminated against by their employer use this form to file a complaint.

F262-009-999

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.

F262-013-000 Occupational Disease Employment History Hearing Loss
Used by injured worker who has filed an occupational hearing loss claim to report their employment history and the nature of the noise exposure at each job. F262-013-111 is the continuation sheet.
F262-013-111 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.
F262-013-999

Historia de Trabajo - Pédida de Audición


Hoja de continuación del formulario, Historia de la pérdida de audición.

F262-016-000 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.
F262-016-999

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.

F262-024-000

Claim Suppression Complaint


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

F262-024-999

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.

F262-032-000 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.
F262-034-000 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.
F262-043-000 Stop Work Payroll Report
Stop Work Payroll Report
F262-044-000 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.
F262-249-909

Workers' Compensation Discrimination / Discriminación porque se lesionó en su trabajo (English/Spanish)


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.

F262-251-000 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.
F262-262-000 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.
F262-262-999

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.

F262-276-000 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.
F262-279-000 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.
F262-280-000 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.
F280-007-000

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.

F280-008-000

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.

F280-010-000 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.
F280-011-000 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.
F280-013-000 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).
F280-016-000

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.

F280-016-999

Acuerdo de Responsabilidad


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.

F280-017-000 Assessing Your Ability to Work: Your Rights and Responsibilities
Booklet: Explains the basics of the assessment phase of vocational services to injured workers. L&I sends this booklet to injured workers when they are referred for assessment services.
F280-017-999

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.

F280-018-000 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.
F280-018-999

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. 

F280-019-000 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.
F280-019-999

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. 

F280-021-000 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.

F280-021-999

Programa con Incentivos para Reemplear Trabajadores Lesionados


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

F280-022-000 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.
F280-023-000

Request for Preferred Workers Status


Used by vocational providers to apply for preferred worker status on behalf of an industrially injured worker.

F280-024-000

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.

F280-024-909

Option 2 Vocational Benefits Training Enrollment Application/Aplicación y Verificación del Registro (English/Spanish)


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.

F280-029-000

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.

F280-029-999

Acuerdo de Responsabilidad de la Capacitación Durante el Transcurso del Trabajo


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

F280-032-000

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.

F280-033-000 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.
F280-036-000 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.
F280-038-000

Vocational Questionnaire/Work History


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

F280-038-999

Cuestionario Vocacional/Historia de trabajo


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

F280-039-000

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


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

F280-045-000

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).

F280-046-000

Referral for WorkSource Services from Private Vocational Provider


Used by private Vocational Providers to refer injured workers to WorkSource

F280-049-000 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.
F280-052-000

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.

F280-052-999

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.

F413-007-000

Application for Asbestos Contractor Certification


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

F413-012-000

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).

F413-012-555

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).

F413-012-777

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).

F413-012-888

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).

F413-012-999

Guía Sobre La Norma de Comunicación de Riesgos Químicos


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).

F413-014-909

Workers' Guide to Hazardous Chemicals / Gua del trabajador para el uso de qumicos (English/Spanish)


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.

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

F413-024-000 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.
F413-024-999

Su cuerpo, su empleo: Prevención del Síndrome del Túnel Carpiano yotros trastornos músculo esqueléticos de las extremidades superiores


Panfleto/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.  

F413-025-000

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.

F413-045-000

Poison Oak Poster (English/Spanish) Cartel sobre el Zumaque Venenoso


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.

F413-047-000 Protecting Yourself and Your Workers from Poison Oak and Ivy (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.
F413-049-000 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.
F413-060-000

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.

F413-060-444 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.
F413-060-999

Sus Pulmones Su trabajo Su vida: Lo que debería saber acerca del asma ocupacional


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

F413-062-000

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.

F413-064-000

Cholinesterase Blood Testing Choice


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

F413-064-999

Elección para Prueba de Sangre de Colinesterasa


Use este formulario para indicar si usted elije o no que se le hagan examenes de Colinesterasa en la sangre.

F413-068-000

Application for Replacement of Lost or Stolen Asbestos Certification Card


This application is for any certified asbestos worker or supervisor that has lost or had their card stolen.

F413-070-000

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.

F413-070-999

Monitoreo de la Colinesterasa - Recomendaciones del Proveedor Médico (Formulario Muestra)


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.

F413-075-000 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.
F414-010-000

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.

F414-012-000

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.

F414-016-000

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.

F414-017-000

Safety Standards for WAC 296-32, Telecommunications


Rules for employees working with telecommunication systems

F414-021-000

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.

F414-025-000

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


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

F414-032-000

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.

F414-033-000

Safety Standards for Construction Work WAC 296-155


Construction work shall mean and include all or any part of excavation, construction, erection, alteration, repair, demolition, and dismantling, of buildings and other structures.

F414-034-000

 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.

F414-036-000

Safety Standards for Fire Fighters WAC 296-305


The rules of this chapter shall apply with respect to any and all activities, operations and equipment of employers and employees involved in providing fire protection services, fire fighters and their work places, including the fire combat scene.

Firefighters are rescuers extensively trained in firefighting, primarily to extinguish hazardous fires that threaten property and civilian or natural populations and to rescue people from dangerous situations, like collapsed or burning buildings.

F414-037-000

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.

F414-038-000

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.

F414-039-000

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.

F414-040-000

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.

F414-042-000

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.

F414-048-000

Safety Standards for WAC 296-59, Ski Area Facilities & Operations


Rules for ski areas

F414-049-000

WAC 296-63 - Right to Know Fee Assessment


Rules for the department to assess and collect Right-to-Know fees.

F414-050-000

Safety Standards for WAC 296-115, Charter Boats


Rules for charter boats not covered by the United States Coast Guard

F414-059-000

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.

F414-068-000

Safety Standards for Confined Spaces WAC 296-809


This chapter applies to all confined spaces and provides requirements to protect employees from the hazards of entering and working in confined spaces.

F414-073-000

WISHA Occupational Exposure to Bloodborne Pathogens - Chapter 296-823 WAC


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

F414-074-034

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).

 

F414-089-000

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.

F414-090-000

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.

F414-109-000

Safety Standards for WAC 296-835, Dip Tanks


The requirements for guarding against the hazards of dip tanks.

F414-112-000

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)

F414-113-000

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.

F414-114-000

Safety Standards for WAC 296-878, Window Cleaning


Safe window cleaning requirements.

F414-117-000

Safety Standards - WAC 296-817, Hearing Loss Prevention (Noise)


Safety Standards - WAC 296-817, Hearing Loss Prevention (Noise)

F414-118-000

Safety Standards for WAC 296-841, Airborne Contaminants


Applies to any workplace with potential or actual employee exposure to respiratory hazards

F414-119-000

Safety Standards for WAC 296-842  - Respirators


An apparatus worn over the mouth and nose or the entire face to prevent the inhalation of dust, smoke, or other noxious substances. Respirator is a type of personal protective equipment designed to protect the wearer from airborne contaminants, oxygen deficiency, or both.

F414-120-000

Safety Standards for WAC 296-843, Hazardous Waste Operations


Rules for hazardous waste sites and operations.

F414-121-000

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.

F414-122-000

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.

F414-124-000

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.

F414-125-000

Safety Standards Machine Safety WAC 296-806


This chapter applies if you have machines or machine operations in your workplace. Machines and their moving parts create the potential for workplace injuries.

F414-126-000

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.

F414-128-000

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.

F414-129-000

Safety Standards for WAC 296-849, Benzene


This chapter applies to all occupational exposure to benzene.

F414-130-000

Safety Standards for WAC 296-848, Arsenic


This chapter applies to all occupational exposure to inorganic arsenic.

F414-132-000

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.

 

F414-133-000

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.

F414-134-000

Safety Standards for WAC 296-811, Fire Brigades


Applies to any workplace that chooses to establish a fire brigade.

F414-135-000

Safety Standards for WAC 296-828, Hazardous Chemicals in Laboratories


Applies to the laboratory use of hazardous chemicals.

F414-136-000

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.

F414-143-000

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.

F414-151-000

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.

F414-154-000 Fall Protection Basics for Construction Activities

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

F414-154-999

Lo Básico Sobre la Protección Contra Caídas en Actividades de la Industria de la Construcción


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.

F414-155-000

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.

F416-011-000

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.

F416-011-999

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.

F416-016-000

Statement


This form is predominately used in non-accident related types of inspections. Used to obtain statements from employees or other individuals whenever it is determined that it would be useful to adequately document an apparent violation.

F416-034-000

Application for Charter Boat Operators License


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

F416-036-000

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.

F416-043-000

Mobile Cranes/Derricks Worksheet for Construction Industry


Mobile Cranes/Derricks Worksheet for Construction Industry

F416-044-000 Tower Crane Worksheet for Construction Industry
F416-051-000

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

F416-052-000

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


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

F416-054-000 Notice of Deficiencies (Crane/Derrick Certification Examination)
Use this form for noting any deficiencies of cranes, derricks, material handling devices, spouts, suckers and similar equipment.
F416-056-000

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

F416-058-000

Charter Vessel Inspection


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

F416-063-000

Application for Accreditation Cranes/Derricks and other Material Handling Devices


Application to become an accredited crane certifier.

F416-081-909

Job Safety and Health Law / Ley de Seguridad y Salud en el Trabajo (English/Spanish)


Required poster: Describes important parts of the Washington Industrial Safety and Health Act (WISHA), which provides for job safety and health of Washington employees. Note: Employers in Washington State must display this poster where workers can see it. When ordering the printed version, you will receive one 22" X 17" poster that includes both languages.

Please order from L&I or print on 11" x 17" paper.

Get poster printing tips.

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

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

F416-087-000

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.

F416-093-000

Witness Statement


Use this form only on accident investigations, fatalities and catastrophies. This form is used to obtain statements from the witness to the accident or personnel who did not witness the accident but have information regarding the incident.

F416-132-000

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

F416-132-999

Una Guía de Seguridad y Salud del Lugar de Trabajo en el Estado de Washington


Panfleto/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.

F416-141-000 Overhead Crane Bridge, Monorail, Gantry Worksheet for Construction
Overhead Crane Bridge, Monorail, Gantry Worksheet for Construction.
F417-014-000

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

F417-031-000 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.
F417-043-000 Guide to Crew Safety Meetings
Pamphlet/booklet: Provides a succinct guide to conducting crew safety meetings for general industry and the construction industry. Includes a format for recording meeting minutes.
F417-048-000

Supervisor's Report of an Accident


Supervisors use this form to document information from an accident or injury.

F417-049-000

Crew Leader Safety Meeting


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

F417-055-909

Quick Tips for Lifting/Consejos Breves para Levantar Cargas (English/Spanish)


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

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

 

F417-087-000

Safety Meeting Minutes


Use this form to record the minutes from your safety meetings - these records must be retained for one year from the date of each meeting

F417-087-999

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.

F417-092-000 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.
F417-102-000

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.

F417-104-000

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.

F417-107-000

Fall Protection Work Plan Requirements


This booklet defines the work plan requirements you must meet for fall protection.

F417-129-000 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.
F417-133-000 Office Ergonomics: Practical solutions for a safer workplace
Book: Provides information and tools to analyze office jobs, find problems and develop ergonomic solutions.
F417-140-000 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.
F417-188-909

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


Poster: Employees have the right to report concerns about safety and health in their workplace. This poster describes "protected activities" under the Washington Industrial Safety and Health Act (WISHA) and explains what an employee should do if he/she has been punished or fired for exercising these rights. Get poster printing tips.

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

F417-195-000

Pocket Guide to Caution Zone Jobs


Pamphlet/booklet: This advisory pocket guide reviews 14 workplace risk factors that can lead to soft tissue injuries such as back strain, tendinitis and carpal tunnel syndrome. Suggests ways to identify the risk factors. Lists helpful resources from L&I.

F417-196-000

Lumber Handling in Sawmills


Book: Developed by mill workers, mill managers and L&I, this manual describes the risks of musculoskeletal injury in lumber-handling jobs. Identifies controls to reduce hazards,increase efficiency and reduce injuries.

F417-202-000

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.

F417-205-000

Borrower Agreement Form Safety and Health Video Library


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

F417-206-000

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.

F417-207-000 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.
F417-208-000 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.
F417-209-000 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.

F417-209-999

Mantenga a sus empleados seguros y trabajando


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

F417-210-000 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.
F417-213-909

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.

F417-214-000 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.
F417-218-909

Heat-related Illness Education Card/Tarjeta de Educación sobre Enfermedades Relacionadas con el Calor (English/Spanish)


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.

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 PDF está configurado para que se impriman dos copias al mismo tiempo.

F417-221-000 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.
F417-222-000

Eye On Safety Card


Reference card: 8.5 X 5.5 card to promote L&I's EyeOnSafety.info website, where you can find video shorts, training videos, investigation stories and other visual resources.

F417-224-000

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.

F417-226-000 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.
F417-227-000

Safety and Health Program Assessment Worksheet


Safety and Health Program Assessment Worksheet

F417-229-000 START Program (Safety through Achieving Recognition Together)
Fact sheet: Provides an overview of START, a program that recognizes occupational safety and health excellence in small businesses. Includes program requirements and benefits.
F417-232-000

Nail Gun Safety: A Guide for Construction Contractors


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

F417-233-000 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.

F417-234-000

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.

F417-234-999

Seguridad con los tractores: Protección contra vuelcos y los cinturones de seguridad


Panfleto/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.

F417-235-000

Q&A: Stay of Abatement Date


Fact sheet: Explains how an employer requests a "stay of abatement date." Effective July 1, 2012, an employer must fix a hazard cited in a workplace inspection during appeal unless he or she has requested and been granted a stay of abatement date.

F417-237-000-A

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.

F417-237-000-B

Demounting and Mounting Procedures for Tube-type Truck and Bus Tires


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-C Multi-piece Rim Matching Chart. This poster must be printed at least 2'x3' in size.

F417-237-000-C

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.

F417-240-000 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.

F417-240-999

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.

F417-241-000

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.

F417-242-000

Q&A: Hazard Communication Standard


Fact sheet: Provides information about changes to OSHA'S Federal Hazard Communication Standard, which triggers the need for changes to Washington State's standard. Rulemaking is under way in 2013. The changes are intended to improve comprehension of hazard information found in product labels to more effectively prevent injuries, illnesses and fatalities.

F417-242-999

P&R: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.

F417-243-000

Washington State Top 25 Hazardous Industries


Booklet: Provides a summary of occupational injury and illness data, including safety and health violations cited, by the top 25 hazardous industries for the five-year period 2006 to 2010.

F417-244-000

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.

F417-244-999

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.

F417-245-000

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.

F417-246-000

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.

F417-248-000 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.

F417-249-000

Logger Safety Initiative Jobsite Notification


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

F417-250-000 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.

F417-251-000

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.

F417-253-000 Rigging Safety: Construction Rigging Requirements

Safety Topic fact sheet: Provides information on how to correctly and safety rig loads on construction job sites to prevent falling material, property damage and equipment failure or tip over. Includes a summary chart of requirements material handling and cranes and derricks.

F418-023-000

Application for Copies of Citation and Notice


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

F418-031-000 Hazard Documentation Worksheet
Hazard Documentation Worksheet for use by L&I compliance staff to describe, measure and comment on workplace hazards.
F418-052-000

Alleged Safety Or Health Hazards (DOSH Complaint Form)


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

F418-052-999

Presuntos Riesgos de Salud y Seguridad (Formulario de Queja de DOSH)


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

F418-055-000

Construction Checklist - Safety


Construction Checklist - Safety

F418-055-999

Lista de Verificación de Seguridad en la Construcción


Lista de verificación de seguridad en la construcción

F500-010-000

Application for Amusement Ride or Air Supported Structure Operating Permit


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

F500-018-000

Application for Electrical Contractors License


Application used to get an electrical contractors license

F500-019-000

Electrical/Telecommunications Contractor's Bond to the State of WA


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

F500-020-000

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.

F500-025-000 Agency Requested Inspection
Used by non-L&I agencies and jurisdictional authorities to request an inspection on an electrical hazard.
F500-032-000

Request for Duplicate or Replacement License or Certificate


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

F500-039-111

Chapter 19.28 RCW - Electricians and Electrical Installations


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

F500-039-222

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


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

F500-043-000

Affidavit of Experience


This affidavit is used to record the hours of a trainee's electrical experience with direct supervision under a Washington certified journeyman, master or specialty electrician.

F500-044-000

Request for Change of Address


Used by electrical licensee to notify L&I of an address change.

F500-045-000

Administrator / Electrician / Master Electrician Certificate Renewal


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

F500-054-000 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
F500-055-000 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.
F500-063-000

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.

F500-065-000

Application for Amusement Ride Inspector Certification


Application to be certified as an amusement ride inspector.

F500-066-000 Affidavit for Amusement Rides
Affidavit of experience to apply for cetification as a Amusement Ride Inspector.
F500-068-000

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.

F500-072-000

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.

F500-076-000 Investigation Report
To notify L&I on any electrical work that you think is illegal.
F500-077-000

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.

F500-078-000 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.
F500-080-000

Account Deposit for Contractor's or Miscellaneous Account Holder's


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

F500-087-000 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.
F500-088-000

Application for Master Electrician Certification Examination


Use this form to apply for the master electrician exam.

F500-090-000

Electrical Continuing Education Instructor Application


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

F500-093-000

Contractor Electrical Work Permit Application


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

F500-094-000

Property Owner Electrical Work Permit Application


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

F500-097-000

Application for a 0% Supervision Modified Electrical Training Certificate & Specialty Examination


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

F500-098-000

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)

F500-101-000

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.

F500-104-000

Application for Pump Installer Combination General Contractor Registration and Electrical Contractor License


Used for creating combination electrical and plumbing contractors license

F500-109-000 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.
F500-110-000 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.
F500-111-000 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.
F500-112-000

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.

F500-113-000 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.
F500-114-000

Electrical Program Contacts


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

F500-115-000 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.
F500-116-000 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.
F500-117-000 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.
F500-123-000

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.

F500-124-000

Electrical Telecommunication Principal Member Owner Update Request


Electrical Telecommunication Principal Member Owner Update Request

F500-127-000

HB 2253 Open Window Opportunity - Affidavit of Hours of Unsupervised Telecommunications Installation Experience


This form is not available until June 12.

F503-008-000

Application for Telecommunications Contractor's License


Application used to get an telecommunications contractors license.

F503-009-000

Change Assignment of Administrator/Master Certificate


To assign or unassign your status as an administrator or master.

F620-012-000 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.
F620-017-000 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. To use this form, left click on the link and select SAVE TARGET AS and save to your desktop. Open in WORD, complete form, select PRINT, SEND TO, MAIL or DELIVERY DOCUMENT ONLY in care of Chief, Boiler Inspector.
F620-025-000 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.
F620-027-000 Shop and Field Inspection Report
Used by L&I inspectors when they inspect boilers.
F620-032-000 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.
F620-040-000

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.

F620-041-000 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.
F620-042-000

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.

F620-043-000 Historical Boilers Inspection Guideline
Inspection sheet for boiler inspectors. 4 pages.
F620-044-000 Incident Report Boiler or Pressure Vessel
Used for the reporting of incident with boilers or a pressure vessels.
F620-048-000 Keep Your Water Heater Safe
Pamphlet/booklet: Describes the process for conducting an annual safety test of a residential water heater. Includes illustrations.
F620-050-000 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
F620-051-000 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
F620-052-000

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

F620-053-000

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

F620-055-000 Board of Boiler Rules Extension of Inspection Frequency Request Form
Board of Boiler Rules Extension of Inspection Frequency Request Form
F620-056-000 Chief Inspector Clarification and Interpretation Request Form
Chief Inspector Clarification and Interpretation Request Form
F620-057-000 Board of Boiler Rules Washington State Specials Request Form
Board of Boiler Rules Washington State Specials Request Form
F620-059-000 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.
F620-060-000

Inservice Inspection checklist


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

F621-001-000

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.

F621-005-000

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.

F621-048-000

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.

F621-050-000

Elevator Information Update


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

F621-051-000

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.

F621-052-000

Hydraulic Overpressure Test


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

F621-053-000

Extension Request


This form is to request a time extension from an unforeseen circumstances for overdue corrections for conveyances.

F621-055-000

Test of Escalator Safety Devices


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

F621-056-000

Conveyance Installation Approval by Building Official


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

F621-057-000

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.

F621-063-000

Owner Requested Red Tag Form


Used by the owner for red tagging a unit that is to be placed or to remain out of service.

F621-065-000

Request for Duplicate Elevator Certificate


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

F621-067-000

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.

F621-068-000

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.

F621-069-000

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.

F621-070-000 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.
F621-077-000

Elevator Continuing Education Course Application


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

F621-078-000

Elevator Continuing Education Instructor Application


Application to become an instructor for elevator related courses.

F621-080-000

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".

F621-082-000

Renewal of Contractor Elevator License


Used by Elevator Companies to renew their Contractor License.

F621-084-000 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.
F621-086-000

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

F621-094-000

Application to Access L&I’s Electronic Permit & Inspection System (EPIS) From Secure Access Washington and Utilize Contractor Deposit Account Via The Internet


F621-095-000

Change Assignment of Primary Point of Contact


Change Assignment of Primary Point of Contact

F621-098-000

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


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

F621-099-000

Request for Duplicate Elevator Mechanic License


Request for Duplicate Elevator Mechanic License

F621-100-000

Elevator Mechanic and Elevator Temporary Mechanic Address/Mailing Information Update


Elevator Mechanic and Elevator Temporary Mechanic Address/Mailing Information Update

F621-105-000

Permit Refund Request


A form to request a refund for an electrical work permit, elevator permit, or factory-assembled structure alteration permit.

F622-006-000

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.

F622-011-000

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.

F622-011-999

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 de HUD para alcanzar los estándares en el área de seguridad contra incendios.

F622-013-000

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.

F622-014-000

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.

F622-015-000

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.

F622-021-000

Application for State Plan Insignia for Recreational Vehicles and Recreational Park Trailers


To apply for an insignia for a recreational vehicle.

F622-021-111

Insignia Continuation Sheet Recreational Vehicles and Park Trailers


Continuation sheet to apply for an insignia.

F622-035-000

Plan Approval Request - Conversion Vendor / Medical Units


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

F622-036-000

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.

F622-038-000

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.

F622-039-000

Alteration Re-Roofing for Low Slope Roofing


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

F622-040-000

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.

F622-043-000

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.

F622-044-000

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.

F622-045-000

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.

F622-046-000

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.

F622-048-000

Gas Piping Test Affidavit


You fill out, print and make a copy of this form on your company's letterhead. This affidavit must be available for the L&I inspector when the inspection is made.

F622-049-000

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.

F622-049-999

Casas prefabricadas y móviles: Lo que los dueños de casas y contratistas deben saber al modificar una vivienda


Panfleto/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.

F622-053-000

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.

F622-054-000

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.

F622-063-000

Decertification of Manufactured and Mobile Homes


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

F622-072-000

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.

F622-073-000 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.
F622-075-000

Structural Inspection Request Questionnaire


Structural Inspection Request Questionnaire

F622-076-000

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.

F622-077-000

Manufactured Home Installer Certification Tag Order form


Manufactured Home Installer Certification Tag Order form

F622-078-000

Manufactured Home Installer's Monthly Certification Tag Report


Manufactured Home Installer's Monthly Certification Tag Report

F622-079-000

Manufactured Home Installer Certification Tag Transfer Request form


Manufactured Home Installer Certification Tag Transfer Request form

F622-080-000

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.

F622-081-000

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.

F623-006-000

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.

F623-013-000

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.

F623-014-000

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.

F623-017-000

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.

F623-019-000

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.

F623-021-000

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.

F625-001-000

Application for Construction Contractor Registration


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

F625-003-000

Continuous Contractor's Surety Bond


This form is used for the surety bond for construction contractors and is required by the Contractor's Registration Act (RCW 18.27). The bond must be produced by a bonding company.

F625-008-000

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.

F625-011-000

Reassignment of Savings Account or Time Deposit - Construction Contractors


Contractors may use this form to request changes to a Assignment of Savings that was filed in lieu of a surety bond or insurance policy.

F625-017-000 Facts About Construction Liens
Fact sheet: Explains the basics of the construction lien law to help consumers protect themselves.
F625-029-000

Waiver of Lien by Contractor, Subcontractor(s) and Supplier


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

F625-030-000

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.

F625-033-000

Contractor Complaint Form


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

F625-040-000

Construction Contractors: Get the Facts, Get Registered


Pamphlet/booklet: Explains the steps to register as a construction contractor in Washington State.

F625-040-999

Contratistas de Construcción: Obtenga los Datos, Regístrese


Panfleto/folleto: Explica los pasos para registrarse como contratista de construcción en el estado de Washington.

F625-051-000

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.

F625-053-000

Filing Suit Against an Electrical Contractor


Instructions for filing suit against an electrical contractor

F625-054-000

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.

F625-055-000 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.

F625-061-000

Contractor Financial Information


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

F625-066-000

Affidavit to Release Public Records


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

F625-069-000

Registered Contractor Card


This is a fillable version of the Registered Contractor Card

F625-077-000

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.

F625-082-000

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.

F625-083-000

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.

F625-084-000

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.

F625-084-999

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.

F625-088-000

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.

F625-094-000

Request for Archive Records - Contractor Registration


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

F625-097-000

Contractors: What if You Get a Notice of Infraction?


Pamphlet/booklet: Tells contractors what their options are and what to do if they get a Notice of Infraction (a non-criminal violation). This publication currently unavailable due to revisions in progress. Check back for updates.

F625-098-000

Washington Contractor's License Bond Validation Rider


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

F625-099-000

Washington Contractor's License Bond Name Change Rider


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

F625-100-000

Washington Contractor's License Bond License Number Change Rider


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

F625-101-000

Washington Contractor's License Bond Date Change Rider


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

F625-102-000

Washington Contractor's License Bond Bond Amount Rider


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

F625-103-000

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.

F625-104-000

Washington Contractor's License Bond Address Change Rider


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

F625-107-000

Renewal Application for Contractor Registration


Renewal Application for Contractor Registration

F625-108-000

Contractor Registration Request for Duplicate License or Address Change

 


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

F625-109-000

Contractor Registration Officers/Members Addendum


Contractor Registration Officers/Members Addendum

F625-110-000

Application for Agent On-Line Insurance Entry Account


Application for Agent On-Line Insurance Entry Account

F625-111-000

Protect My Home Hire Smart Worksheet


Checklist: Provides information to help screen potential contractors for home construction or repair/remodel projects. Presented in an organized, step-by-step format.

F625-111-999

Hoja para Contratar un Contratista con Éxito


Lista: Proporciona información para ayudar a  escrutinar  posibles contratistas para proyectos de construcción de casas o reparación/remodelación.  Presentado en un formato organizado y detallado.

F625-113-000

Upgrade from Specialty Contractor to General Contractor


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

F626-001-000

Application for Electrician Examination


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

F626-048-000

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).

F627-003-000

Application for Plumber Trainee Certificate


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

F627-004-000

Affidavit of Experience - Plumbers


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

F627-008-000

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.

F627-014-000

Request for Duplicate or Replacement Certificate


This form is used to request a duplicate or replacement certificate for a plumber or plumber trainee.

F627-019-000

Plumber, Medical Gas, or Trainee Renewal


This form is used to renew a plumber certification, plumber trainee or medical gas installer certification.

F627-022-000 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.
F627-026-000 Facts about Medical Gas Piping Installer Endorsement
Fact sheet: Explains training requirements and the endorsement process for medical gas piping installers.
F627-027-000

Plumbers Examination Dates and Locations


The 2014 Plumber Examination Dates and Locations. A printed version is also available from the L&I Warehouse.

F627-033-000

Application for Backflow Trainee Certificate


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

F627-035-000

Application for Backflow Specialty Exam


This form is used to apply for the backflow specialty examination.

F627-037-000

Plumber Continuing Education Course Application


This form is used by the course sponsor to submit continuing education courses for plumber certification.

F627-039-000 Plumber Request for Change of Address
Plumber Request for Change of Address
F627-043-000

Affidavit of Continuity Medical Gas Installation


Affidavit of Continuity

F627-044-000

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.

F700-002-000

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  

F700-007-000

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.

F700-009-000

Record Keeping Provisions - Employment Standards


This form is for employers to use to keep records on every employee.

F700-010-000 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).
F700-014-000

Application for Farm Labor Contractor License


Used to apply or renew a license.

F700-022-000

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.

F700-022-999

Adolescentes en el trabajo: Información para empleadores, padres y adolescentes


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

F700-024-000

Wage Transcription and Computation Sheet


Employer uses this to show time worked and wages earned for an employee.

F700-029-000

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.

F700-032-000

Washington State Prevailing Wage Law


Booklet: Contains the prevailing wage laws (RCWs) and rules (WACs) as well as plain language descriptions and contact information.

F700-046-000

Agreement - Farm Labor Contractors and Workers


Employment wages and conditions agreement with Farm Labor Contractors and Workers

F700-046-999

Acuerdo entre Contratistas Agrícolas y Trabajadores


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

F700-051-000

Minimum Wage Law Exemptions


Covers exemptions to Washington state minimum wage law.

F700-058-000

Employer Rights - Wages Paid


Covers penalties for employer wage violations. Once stock runs out in warehouse, this form will be internet only.

F700-060-000

Farm Labor Contractor Assignment of Account or Time Deposit


Farm Labor Contractor assignment of account or tme deposit for employee

F700-064-000

Payment of Wages - RCW 49.48.010 and 49.52.050


This is a copy of the law that pretains to the payment of wages to an employee when they stop working for an employer. The wages due to the employee for the pay period worked prior to leaving.

F700-065-000

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.

F700-066-000

Farm Labor Contractors Bond


Notarized farm labor contractors bond coverage.

F700-067-000

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.

F700-067-909

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


Fact sheet: Explains workers' rights when they are employed by a farm labor contractor. Topics covered include workplace safety, rest and meal breaks, and help if injured on the job.

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

F700-074-909

Your Rights as a Worker in Washington State/ Sus Derechos como Trabajador en el Estado de Washington (English/Spanish)


Required poster: Reviews workers' rights under Washington's wage-and-hour laws. Topics include minimum wage, overtime, meal and rest breaks, pay periods, deductions, and employment of teens under age 18. Also reviews family leave provisions under federal and state law, and leave for spouses of deploying military personnel and victims of domestic violence. Note: Employers in both agricultural and non-agricultural industries in Washington State must display this poster where workers can see it.

Please order from L&I or print on 11" x 17" paper.

Get poster printing tips.

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

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

Obtenga consejos para imprimir carteles. 

 

 

 

F700-076-000

Variance Application - For exceptions from specific rules governing employment of minors.


Employer uses this application for requesting a variance to employment regulations for minors.

F700-079-000

Washington State OverTime Law


Covers compensation for employees in Washington State working overime.

F700-084-000

Nonagricultural Employment of Minors Chapter 296-125 WAC


Nonagricultural Employment of Minors Chapter 296-125 WAC

F700-085-000

Chapter 296-131 WAC Agriculture Employment Standard


F700-085-999

Estándares de Trabajo Agrícola Capítulo 296-131 del Código Administrativo de Washington (WAC, por su sigla en inglés)


Estándares de trabajo agrícola - Capítulo 296-131 del Código Administrativo de Washington (WAC, por su sigla en inglés)

F700-088-000

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.

F700-088-999

Farm Labor Contractor Registration


Hoja de datos:  Explica cómo obtener una licencia de contratista agrícola para poder operar legalmente como un contratista agrícola en el estado de Washington.

F700-089-000

Variance Application - Employment Standards


Employer application request for a variance from employment standards for non minor employees.

F700-095-000

Minimum Wage Law - Truck Drivers


Record keeping provisions and overtime for truck & bus drivers.

F700-096-909

Young Workers in Agriculture / Trabajadores jóvenes en la agricultura (English/Spanish)


Pamphlet/booklet: Answers many questions employers and minor workers have about employing minors. Covers agriculture work rules, including the necessary permits, hours and work conditions for workers 12-17 years of age.

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

F700-097-000

Washington State Deduction Laws


Deductions for current & terminated employees and employer liability for paying less than required.

F700-098-000

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.

F700-099-000

Department of Employment Security Tax Compliance Certification


Form to gain Department of Employment Security Tax Compliance Certification for registered Farm Labor Contractors.

F700-100-000

Department of Revenue Tax Compliance Certification


Form to gain Department of Revenue Tax Compliance Certification for registered Farm Labor Contractors.

F700-105-909

Your Daily Record of Hours Worked / Su Registro de Horas Trabajadas (English/Spanish)


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

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

F700-109-000

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.

F700-109-999

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.

F700-112-000

Farm Labor Contractor Checklist


Farm Labor Contractor's Checklist to ensure compliance.

F700-112-999

Lista de Comprobacion para un Contratista de Trabajores Agrícolas (Farm Labor Contactor Checklist)


Lista de verificación para el contratista de trabajadores agrícola para asegurar el cumplimiento.

F700-117-000

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.

F700-118-000

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.

F700-119-000

Court Form Granting Permission for Employment of Minors


Form from Court Granting Permission for Employment of Minors to the employer.

F700-120-000

Application for Special Certificate to Employ at A Subminimum Wage Rate


Employer Application for Special Certificate to Employ at A Subminimum Wage Rate.

F700-121-000

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.

F700-122-000

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

F700-124-000

Summary of Agricultural Employment Regulations and Farm Contractor Requirements


This summary is on employment laws relating to the agricultural industry.

F700-125-000

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.

F700-129-000

Interested Party Checklist for the Filing of Prevailing Wage Complaints


Checklist used for the filing of Prevailing Wage Complaints by "Interested parties" ONLY.

F700-130-000

Sports Teams and Youth Workers


Fact sheet: Explains the requirements for sports organizations that engage young people as volunteers or employees to referee, assist or work for the organizations. The focus is workers' compensation coverage and minor work rules.

F700-135-000

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.

F700-136-000 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.
F700-139-000 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.
F700-140-000 Restaurant Employee Safety Orientation Checklist
Fact Sheet: Download this checklist to help with the safety orientation of new restaurant employees.
F700-141-000

Request for Assistance in Obtaining Certified Payroll Records


Used to request copies of Certified Payrolls for prevailing wage projects.

F700-142-909

Hiring teens? / ¿Piensa contratar adolescentes? (English/Spanish)


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.

 

F700-143-000

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.

F700-144-000

Protected Leave Complaint


For leave from work complaints: Download and complete a Protected Leave Complaint form (F700-144-000)

F700-144-999

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 (F700-144-999)

F700-145-909

Youth in Construction / Adolescentes en construcción  (English/Spanish)


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.

Folleto/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.

F700-146-000

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.

F700-146-999

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.

F700-147-000 Farm Labor Contractor Certified Payroll
Farm Labor Contractor Certified Payroll
F700-148-000

Worker Rights Complaint Form


This is the Worker Rights Complaint Form. Both the 12-2011 and 10-2010 versions are valid.

F700-148-999

Formulario de Queja sobre los Derechos Laborales


Formulario de queja sobre los derechos laborales.  Las versiones de octubre de 2010 y de diciembre 2011 son válidas.

F700-150-000

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.

F700-152-999

Resumen de las Leyes de Salario Prevaleciente en Lenguaje Sencillo Entienda sus Responsabilidades y Derechos al Hacer Trabajos Públicos


Hojas 8.5 pulgadas x 11 pulgadas: 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.

F700-153-909

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/Spanish)


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.

F700-154-909

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/Spanish)


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.

 

F700-157-000

Farm Internship Agreement


Agreement form: Prior to hiring an intern, farms that have received a Farm Intern Program certificate must complete this agreement with the intern and submit it to the department.

F700-158-000

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.

F700-160-000

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.

F700-161-000

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.

F700-162-000

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.

F700-163-000

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.

F700-164-000 Affidavit of Wages Paid EHB 2805 Addendum
F700-164-000 is an addendum to your Affidavit of Wages Paid Form. RCW 39.04.370 requires you to complete form F700-164-000 if the prime contract is at a cost of over one million dollars ($1,000,000). If you fail to properly provide the requested information more than one time between September 1, 2010 and December 31, 2013, pursuant to RCW 39.04.350(1)(f) you will not be considered a responsible bidder qualified to be awarded a public works project. Use as many of these forms as you need in order to provide the requested information for all relevant project items. This is an addendum to form F700-007-000.
F700-165-000

Affidavit of Wages Paid Addendum D


Please use this addendum to provide the details of the Apprentices associated with your Affidavit of Wages of Paid. Addendum D is for form F700-007-000.

F700-166-000

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.

F700-167-000

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.

F700-168-000

Parent Authorization Summer Work


This form is for summer employment of minors, only, and is for parents or legal guardians to approve the hours and work activities for a minor employee to work according to terms listed by the employer.  All parties must sign to approve the work schedule and duties for a minor prior to permitting them to work.  This is NOT a work permit.  Employers must obtain a minor work permit endorsement on their Business License where they employ workers under 18.

F700-169-909

Your Daily Record of Hours and Units Worked - For Agricultural Workers / Su Registro Diario de Horas y Unidades Trabajadas - Para Trabajadores Agrícolas (English/Spanish)


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 exhortar a los trabajadores agrícolas a mantener un registro de sus horas de trabajo diarias, unidades e ingresos.

F700-170-000

Farm Labor Contractor Application/Renewal Packet


This is the packet you would complete to register as a farm labor contractor.

F700-171-000

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.

F700-171-999

Cómo calcular su salario en agricultura


Hoja de información: Muestra a los trabajadores por contrato como calcular sus salarios y verificar si le están pagando salario mínimo.

F700-172-000

Farm Internship Project Complaint Form


Complaint form for public to complete and submit

F700-173-000

Unpaid Internships 101


Fact sheet: Document provides information as the state and federal restrictions for unpaid interns who are in an educational capacity in a workplace.

F800-006-909

Help for Victims of Crime / Ayuda para víctimas de crimen (English/Spanish)


Pamphlet/booklet: Answers questions about Washington State's Crime Victims Compensation Program, who may be eligible for benefits and how to apply.

Pamfleto/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. 

 

F800-025-000

Statement for Crime Victims Mental Health Services


Used by the Crime Victims Compensation Program providers for reimbursement of Mental Health Services.

F800-031-000

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.

F800-031-999

Aplicación 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.

F800-041-000

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.

F800-041-999

Ayuda para Víctimas de Crimen (cartel grande)


Cartel (11" X 17"): 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 imprirse o solicitarse de L&I.  Hay una versión más pequeña (8.5" X 11") disponible.

F800-042-000

Application for Benefits - Crime Victims


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

F800-042-999

Instrucciones para: Solicitud para Beneficios para Víctimas de Crimen


Instrucciones en español para completar el formulario F800-042-000, Solicitud para beneficios para víctimas de crimen.  El formulario es utilizado por víctimas de crimen en el estado de Washington para recibir beneficios de tiempo perdido del trabajo, pérdida de apoyo económico, tratamiento médico y de salud mental.  Esta versión del 10 de diciembre está en Internet solamente.

F800-049-000

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.

F800-053-000 Master Level Counselor Provider Account Application for Crime Victims

Master Level Counselor Provider Account Application for Crime Victims

F800-057-909

Request for Survivor Counseling Benefits / Solicitud para Beneficios de Apoyo para los Sobrevivientes (English/Spanish)

 


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

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

F800-058-000

Crime Victims Statement for Pharmacy Services


Used by Crime Victims Compensation Program providers to bill for pharmacy services. Crime Victims Compensation Program providers are required to bill using this form.

F800-064-000

Crime Victims Provider's Request for Adjustment


Used by providers to request an adjustment to their bill if their entire bill was paid in error, or if a portion of the bill was overpaid or underpaid. Attach required reports and/or documentation to support the request.

F800-065-000

Statewide Payee Registration and W-9 Form Crime Victims


Used by a provider assisting victims of crime to obtain a taxpayer ID number. Note: Register now for direct deposit available January 2013.

F800-067-000

Crime Victims' Statement for Compound Prescription


Bill form for use by pharmacies and home infusion companies to submit compound drug charges for Crime Victims Compensation. This form is for drug charges only and is filled out by the pharmacist.

F800-070-000

Crime Victims Statement for Home Nursing Services


Used by the Crime Victims Compensation Program providers for reimbursement of home nursing services. Crime Victims Compensation Program providers are required to bill using this form.

F800-074-000

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.

F800-076-000

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.

F800-080-000 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).
F800-081-000

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)

F800-082-000

Crime Victims Compensation Program Progress Note: Form III


Used by the clinical provider to submit a request for preauthorization for payment of additional sessions.

F800-083-000

Crime Victims Compensation Program Treatment Report: Form IV


Used by the clinical provider to request preauthorization for payment of additional sessions.

F800-084-000

Crime Victims Compensation Program Treatment Report: Form V


Used by the clinical provider to get preauthorization for payment of additional sessions.

F800-085-000

Crime Victims Compensation Program Termination Report: Form VI


Used by the clinical provider to inform L&I that you are no longer conducting treatment to the client. This must be submitted within 60 days of the client's last session and you are no longer conducting treatment.

F800-089-000

Provider Change Form for Crime Victims Compensation


Providers use to inform L&I that they have changes to their account. Such as changes to their Tax ID address/name, business address, billing address, name, or termination of account. This also includes a W-9 form.

F800-098-000

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.

F800-100-000

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.

F800-102-000 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.
F800-104-000

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").

F800-104-999

Ayuda para Víctimas de Crimen (cartel)


Cartel (8.5" X 11"): 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 imprirse o solicitarse de L&I. Hay una versión más grande (11" X 17") disponible.

F800-105-000

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.

F800-110-000

Victim Verification Form


For use by crime victims requesting wage replacement compensation

F800-110-999

Formulario de Verificación de Empleo


Para ser utilizado por las víctimas de crimen que están solicitando compensación de reemplazo de salario.

F800-112-000

Crime Victims Address Change Request


Crime Victims Address Change Request

F800-115-000 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.
F800-116-000

CVCP Opioid Progress Report Chronic, Non-Cancer Pain and Treatment Agreement.


Crime Victims Compensation Opioid Progress Report Chronic, Non-Cancer Pain and Treatment Agreement.

F800-118-000 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).
F800-119-000 Crime Victims Compensation Subacute Opioid Request Form
Use this form for Crime Victims Compensation to request opioid coverage between 6 weeks and 12 weeks from date of injury or surgery.
F888-888-888 test form

This is a test

FSP0-900-001 Sticker - Emergency Information
FSP0-901-000 Safety Comes Thru Job Training
A supervisor having a discussion with his crew. Get poster printing tips.
FSP0-903-000 Ten Safe Handling Hints for Knives
Shows ten tips on handling a knife safely. Get poster printing tips.
FSP0-904-000 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.
FSP0-905-000 Fryer Safety
Tips on deep frying safety. Get poster printing tips.
FSP0-906-000 Ten Steps for Avoiding Burns
Tips on how to avoid burns while cooking. Get poster printing tips.
FSP0-907-000 Job Site Safety: Wear Your Hard Hat
Poster: Visual reminder you can print for posting at appropriate job sites and use in safety training, crew or safety committee meetings.
FSP0-908-000 Stay Clear of Suspended Loads
Pictures a guy under a suspended wooden carton. Get poster printing tips.
FSP0-910-000

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.

FSP0-912-000

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.

FSP0-915-000 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.
FSP0-918-000 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.
FSP0-919-000 Robberies and Abusive Customers: Tips for Preventing Injuries
Tips on handling cash and how to have a safer restaurant or retail environment. Get poster printing tips.
FSP0-919-999

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.

FSP0-928-000 Caution: Hard Hat Area
Visual reminder of the importance of wearing a hard hat. Get poster printing tips.
FSP0-928-999

Caution: Hard Hat Area / Precaución: Obligatorio Usar Casco (English/Spanish)


Picture of hard hats. Get poster printing tips.

Fotografía de cascos.  Obtenga información sobre cómo imprimir carteles.

FSP0-940-000 Always Wear Eye Protection
Picture of a large eye with some content on when to use eye protection. Get poster printing tips.
FSP0-940-999

Siempre Use Protección para los ojos (English/Spanish)


Fotografía de un ojo grande con contenido sobre cuando debe usar protección de los ojos. Obtenga información sobre cómo imprimir carteles.

FSP0-941-000

Always Wear Eye Protection


Sticker: 7.25 inches X 4.25 inches.

FSP0-951-000 Ladder Safety
Picture of a ladder with safety tips on the rungs. Get poster printing tips.
FSP0-954-000 Keys to Safety
Picture of two keys with the words 'Skills' and Knowledge' on them. Get poster printing tips.
FSP0-972-000

Danger! Minimum Clearance for Counter Balance - Logging


FSP0-972-000

Sticker - Danger! Minimum Clearance - Logging


Sticker size = 8.25 x 6.

FSP0-974-000

Danger! Minimum Clearance for Counter Balance - Construction


Sticker: 30 inches long.

FSP0-978-000 Safe Ways - Fork Lift Safety
Safety tips on using a fork lift. Get poster printing tips.
FSP0-993-000

Put this Guard Back - 8.5 x 3.5 inches


This sticker is for employers to place on their equipment to inform workers that if they must remove the guard for service or maintenance to be sure to put it back immediately.

FSP0-993-001

Put this Guard Back - 5 1/2 x 2 1/8 inches


Sticker: 5 1/2 inches X 2 1/8 inches

FSP0-993-991

Si usted TIENE que remover este resguardo 5 1/2 x 2 1/8


Etiqueta adhesiva: 5.5 pulgadas x 2.15 pulgadas. Esta etiqueta adhesiva es para que los empleadores la coloquen en su equipo para informarles a los trabajadores que si necesitan quitar el resguardo de seguridad o mantenimiento deben asegurarse de volver a colocarlo inmediatamente.

FSP0-993-999

Si usted TIENE que remover este resguardo 8.5 x 5.5


Etiqueta adhesiva: 8.5 pulgadas x 3.5 pulgadas. Esta etiqueta adhesiva es para que los empleadores la coloquen en su equipo para informarles a los trabajadores que si necesitan quitar el resguardo de seguridad o mantenimiento deben asegurarse de volver a colocarlo inmediatamente.

FSP1-000-000

Grinding Wheel - Prevent Accidents


Sticker size 4"x3"

FSP1-004-000 Report All Injuries Promptly
Large words: Report All Injuries Promptly. Get poster printing tips.
FSP1-004-999

Report All Injuries Promptly / Reporte Todas las Lesiones Inmediatamente (English / Spanish)


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.

FSP1-005-000

First Aid


Safety Sticker size 5"x6"

FSP1-010-000 Well...My Daddy Wears 'Em
Little boy wearing his daddy's hard hat, eye protection, gloves and boots. Get poster printing tips.
FSP1-012-000 Danger, Workers Above
Picture of workers on a high rise. Get poster printing tips.
FSP1-012-999

Danger, Workers Above / Peligro - Trabajadores en el Nivel Superior (English/Spanish)


Picture of workers on a high rise. Get poster printing tips.

Fotografía de unos trabajadores en una superficie alta.  Obtenga instrucciones sobre cómo imprimir los carteles.

FSP1-013-000 Danger, Construction Area Authorized Personnel Only
Large words: Danger, Construction Area Authorized Personnel Only. Get poster printing tips.
FSP1-013-999

Peligro - Área en Construcción - Solamente Personas Authorizadas


Large words: Peligro - Área en Construcción -  Solamente Personas Authorizadas. Get poster printing tips.

FSP1-030-000 Danger
Large lettering: DANGER. Get poster printing tips.
FSP1-030-999

Danger / Cartel - PELIGRO (English/Spanish)


Large lettering: DANGER. Get poster printing tips.

En letras grandes: PELIGRO

FSP1-051-000 Walk, Don't Run
Timeless reminder to walk, don't run, showing a banana peel. Get poster printing tips.
FSP1-055-000 Watch Where You Step
Large lettering: Watch Where You Step. Get poster printing tips.
FSP1-063-000 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.
FSP1-065-000 High Noise Area, Wear Hearing Protection
Cartoon of a guy plugging his ears with his fingers while his hearing protection is wrapped around his neck with the words 'High Noise Area' above his head. Get poster printing tips.

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