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

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



Form
F500-080-000


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

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



Form
F500-080-000


 
Account Deposit for Factory Assembled Structures Account Holders

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



Form
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.



Form
F622-081-000


 
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.



Form
F280-016-000



Alt Language(s):
Español
 
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



Form
F500-054-000


 
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)



Form
F120-116-000


 
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.



Form
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.



Form
F625-082-000


 
Assignment of Account or Time Deposit for Insurance - Property Damage - WA State Banks Only

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



Form
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.



Form
F625-083-000


 
Authorization for Deposit of Payments

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



Form
F242-174-000



Alt Language(s):
English/Español
 
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.



Form
F625-077-000


 
Contractor Financial Information

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



Form
F625-061-000


 
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.



Form
F500-020-000


 
Farm Labor Contractor Assignment of Account or Time Deposit

Farm Labor Contractor assignment of account or tme deposit for employee



Form
F700-060-000


 
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.



Form
F800-089-000


 
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.



Form
F500-072-000


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

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



Form
F245-043-000


 
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.



Form
F800-065-000


 
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.



Form
F245-055-000


 
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.



Publication
F200-019-000


 
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.



Publication
F200-022-000


 
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.

Form
F207-143-000


 
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.

Form
F207-039-000


 





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