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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
 
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.



Form
F242-067-000
 
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.



Form
F280-008-000
 





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