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.

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.

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.

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

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

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.

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.

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.

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.

Used to obtain a vocational provider account number with L&I. This form includes a copy of F248-036-000 "Request for Taxpayer ID number and Certification". (12 pages) CURRENT EXISTING VOCATIONAL PROVIDER FIRMS THAT ARE ALREADY REGISTERED WITH L&I USE THIS FORM AND W-9.

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

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

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.

Application for Agent On-Line Insurance Entry Account

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.

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

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)

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

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.

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.

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

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

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.

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

Farm Labor Contractor assignment of account or tme deposit for employee

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.

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.

This form has a list of mailing addresses and document types a provider uses to send to L&I. There is also a list of phone numbers.

Master Level Counselor Provider Account Application for Crime Victims

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).

OJT Accountability Agreement in Spanish

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.

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.

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.

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.

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.

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

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.

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.

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