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Accountability Agreement
Form
F280-016-000  
Address Change Request for Pensioners
Form
F242-107-000

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

World Language(s):
Español  
Agreement of Assumption and Guarantee of Workers' Compensation Liabilities (Certified Self-Insurer)
Form
F207-040-001  
Agreement of Assumption and Guarantee of Workers' Compensation Liabilities - Application of Certification
Form
F207-040-000  
Alteration Polybutylene Re-Pipe Pre-Inspection Checklist
Checklist
F622-053-000  
An Employer's Intro to L&I
Publication
F101-101-000  
Application for Insignia Conversion Vendor/Medical Units
Form
F623-021-000  
Application for Pension Benefits by Spouse or Children
Form
F242-391-000

World Language(s):
Español  
Application for Pension Benefits by Spouse or Children
Form
F242-391-000

World Language(s):
Español  
Application for Special Certificate to Employ A Vocationally Handicapped Worker at at Subprevailing Wage Rate
Form
F700-122-000  
Application for Special Certificate to Employ A Vocationally Handicapped Worker at at Subprevailing Wage Rate
Form
F700-122-000  
Application for Special Certificate to Employ A Vocationally Handicapped Worker at at Subprevailing Wage Rate
Form
F700-122-000  
Assessment Eligible Quality Assurance Review Form
Form
F280-008-000  
Authorization for Deposit of Payments
Form
F242-174-000

World Language(s):
English/Español  
Authorization for Deposit of Payments
Form
F242-174-000

World Language(s):
English/Español  
Billing Guidelines for Sexual Assault Examinations: Crime Victims Compensation Program
Manual
F800-100-000  
Casas prefabricadas y móviles: lo que los dueños de casas y contratistas deben saber al modificar una vivienda
Publication
F622-049-999

World Language(s):
Inglés  
Certificado de cobertura - ejemplo
Form
F211-141-999

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

World Language(s):
Español  
Copper Tubing Gas Line Pre-Inspection Checklist
Checklist
F622-046-000  
Court Form Granting Permission for Employment of Minors
Form
F700-119-000  
Crime Victims Direct Entry Billing Manual
Manual
F800-118-000  
Crime Victims Direct Entry Billing Manual
Manual
F800-118-000  
Crime Victims Direct Entry Billing Manual
Manual
F800-118-000  
Crime Victims Statement for Home Nursing Services
Form
F800-070-000  
Crime Victims Statement for Home Nursing Services
Form
F800-070-000  
Crime Victims Statement for Home Nursing Services
Form
F800-070-000  
Crime Victims Statement for Pharmacy Services
Form
F800-058-000  
Crime Victims Statement for Pharmacy Services
Form
F800-058-000  
Crime Victims Provider's Request for Adjustment
Form
F800-064-000  
Crime Victims Provider's Request for Adjustment
Form
F800-064-000  
Crime Victims Provider's Request for Adjustment
Form
F800-064-000  
Cuestionario para beneficios de pensión
Form
F242-393-999

World Language(s):
Inglés  
Decertification of Manufactured and Mobile Homes
Form
F622-063-000  
Declaración de derechos para dependientes del trabajador fallecido bajo el Programa de Compensación y Beneficios para Trabajadores
Form
F242-173-933

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

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

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

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

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

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

World Language(s):
Inglés  
Declaración para servicios misceláneos
Form
F245-072-999

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

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

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

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

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

World Language(s):
Español  
Desarrollo del plan: ¿Cuáles son mis derechos y responsabilidades? Servicios de rehabilitación vocacional
Publication
F280-018-999

World Language(s):
Inglés  
Desarrollo del plan: ¿Cuáles son mis derechos y responsabilidades? Servicios de rehabilitación vocacional
Publication
F280-018-999

World Language(s):
Inglés  
Electronic Billing Authorization
Form
F248-031-000  
Electronic Billing Authorization
Form
F248-031-000  
Employer Petition to The Court for Minor Work Permit Under Age 14
Form
F700-118-000  
Evaluando su capacidad para trabajar: sus derechos y responsabilidades, servicios de rehabilitación vocacional
Publication
F280-017-999

World Language(s):
Inglés  
Evaluando su capacidad para trabajar: sus derechos y responsabilidades, servicios de rehabilitación vocacional
Publication
F280-017-999

World Language(s):
Inglés  
Gas Piping Test Affidavit
Form
F622-048-000  
Gas Room Heaters Pre-Inspection Checklist
Checklist
F622-045-000  
General Provider Billing Manual
Manual
F248-100-000  
General Provider Billing Manual
Manual
F248-100-000  
General Provider Billing Manual
Manual
F248-100-000  
Homeowners Manufactured / Mobile Home Variance Request
Form
F622-054-000  
Job Modification Assistance Application
Form
F245-346-000

World Language(s):
Español  
Job Modification Assistance Application
Form
F245-346-000

World Language(s):
Español  
Llevando a cabo su plan vocacional: sus derechos y responsabilidades durante el plan de implementación, Servicios de rehabilitación vocacional
Publication
F280-019-999

World Language(s):
Inglés  
Medical Examiners' Handbook
Publication
F252-001-000  
Non-accredited or Unlicensed Training Provider Application Supplemental Requirements
Form
F280-045-000  
Notificación de decisión de cierre con discapacidad parcial permanente para empleadores autoasegurados - DISCAPACIDAD PARCIAL PERMANENTE (PPD) - SIN TIEMPO PERDIDO (NTL)
Form
F207-165-999

World Language(s):
Inglés  
Notificación de decisión de cierre con discapacidad parcial permanente para empleadores autoasegurados - DISCAPACIDAD PARCIAL PERMANENTE (PPD) - SIN TIEMPO PERDIDO (NTL)
Form
F207-165-999

World Language(s):
Inglés  
Notificación de decisión de cierre con discapacidad parcial permanente para empleadores autoasegurados - DISCAPACIDAD PARCIAL PERMANENTE (PPD) - SIN TIEMPO PERDIDO (NTL)
Form
F207-165-999

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

World Language(s):
Inglés  
Option 2 Vocational Benefits Training Enrollment Application and Verification
Form
F280-024-000

World Language(s):
English/Español  
Option 2 Vocational Benefits Training Enrollment Application/Solicitud y verificación del registro para capacitación de beneficios vocacionales opción 2 (English/español)
Form
F280-024-909

World Language(s):
Inglés  
Parent / School Authorization for Employment of a Minor and Special Variance
Form
F700-002-000  
Pension Benefits Questionnaire
Form
F242-393-000

World Language(s):
Español  
Pension Benefits Questionnaire
Form
F242-393-000

World Language(s):
Español  
Pension Benefits Questionnaire
Form
F242-393-000

World Language(s):
Español  
Plan Approval Request - Factory Built Structures and Commercial Coaches
Form
F623-006-000  
Plan Development Quality Assurance Review Form
Form
F280-007-000  
Plan Room and Board Cost Encumbrance
Form
F245-372-000  
Power of Attorney for Electronic Remittance Advice
Form
F248-355-000  
Power of Attorney for Electronic Remittance Advice
Form
F248-355-000  
Power of Attorney for Electronic Remittance Advice
Form
F248-355-000  
Pre-Job Accommodation Assistance Application
Form
F245-350-000

World Language(s):
Español  
Preferred Worker Status Request
Form
F280-023-000  
Provider's Request for Adjustment
Form
F245-183-000  
Provider's Request for Adjustment
Form
F245-183-000  
Reclamo para beneficios de pensión presentado por los dependientes
Form
F242-062-999

World Language(s):
Inglés  
Reclamo para beneficios de pensión presentado por los dependientes
Form
F242-062-999

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

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

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

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

World Language(s):
Inglés  
Referral to Labor and Industries /WorkSource Partnership Services
Form
F280-046-000  
Self-Insurance Medical Provider Billing Dispute form
Form
F207-207-000  
Self-Insurance Medical Provider Billing Dispute form
Form
F207-207-000  
Self-Insurance Medical Provider Billing Dispute form
Form
F207-207-000  
Self-Insurance Medical Provider Billing Dispute form
Form
F207-207-000  
Self-Insurance Medical Provider Billing Dispute form
Form
F207-207-000  
Self-Insurance Medical Provider Billing Dispute form
Form
F207-207-000  
Self-Insurance Vocational Reporting Form
Form
F207-190-000  
Self-Insured Employers' Permanent Partial Disability Closure Order and Notice - PPD-TL
Form
F207-164-000

World Language(s):
Español  
Self-Insurer's Pension Bond
Form
F207-065-000  
Solicitud para beneficios de pensión presentado por el cónyuge o los hijos
Form
F242-391-999

World Language(s):
Inglés  
Solicitud para beneficios de pensión presentado por el cónyuge o los hijos
Form
F242-391-999

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

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

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

World Language(s):
Inglés  
Statement for Crime Victim Miscellaneous Services
Form
F800-076-000  
Statement for Crime Victim Miscellaneous Services
Form
F800-076-000  
Statement for Crime Victims Mental Health Services
Form
F800-025-000  
Statement for Crime Victims Mental Health Services
Form
F800-025-000  
Statement for Retraining and Job Modification Services
Form
F245-030-000

World Language(s):
Español  
Steel or Wrought-Iron Gas Line Pre-Inspection Checklist
Checklist
F622-044-000  
Time Encumbrance Form
Form
F245-376-000  
Training Plan Cost Encumbrance
Form
F245-374-000  
Transportation Cost Encumbrance
Form
F245-375-000  
UB04 HCFA 1450
Form
F245-367-000  
UB04 HCFA 1450
Form
F245-367-000  
Vocational Training Plan Ownership Agreement for Tools and Equipment
Form
F245-351-000

World Language(s):
Español  
Vocational Training Plan Ownership Agreement for Tools and Equipment
Form
F245-351-000

World Language(s):
Español  
Vocational Training Plan Ownership Agreement for Tools and Equipment
Form
F245-351-000

World Language(s):
Español  
Address Change Request for Injured Workers
Form
F242-388-000

World Language(s):
Español  
ASC X12N 005010 EDI Transactions Companion Guide
Manual
F245-398-000  
Assessing Your Ability to Work: Your Rights and Responsibilities
Publication
F280-017-000

World Language(s):
Español  
Assignment of Account Agreement
Form
F207-058-000  
Carrying Out Your Vocational Plan: Your Rights and Responsibilities During Plan Implementation
Publication
F280-019-000

World Language(s):
Español  
Carrying Out Your Vocational Plan: Your Rights and Responsibilities During Plan Implementation
Publication
F280-019-000

World Language(s):
Español  
Carrying Out Your Vocational Plan: Your Rights and Responsibilities During Plan Implementation
Publication
F280-019-000

World Language(s):
Español  
Claim for Pension By Dependents
Form
F242-062-000

World Language(s):
Español  
Claim for Pension By Dependents
Form
F242-062-000

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

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

World Language(s):
Español  
Declaration of Entitlement for Guardian Benefits under Industrial Insurance
Form
F242-173-222

World Language(s):
Español  
Declaration of Entitlement for Guardian Benefits under Industrial Insurance
Form
F242-173-222

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

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

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

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

World Language(s):
Español  
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.)
Form
F245-392-000  
Helping Providers Understand the Crime Victims Compensation Program
Publication
F800-102-000  
Intent to Hire Preferred Worker with Developmental Disabilities
Form
F280-011-000  
Letter of Intent for School Enrollment
Form
F242-382-000

World Language(s):
Español  
Letter of Intent for School Enrollment
Form
F242-382-000

World Language(s):
Español  
Limited Liability Companies (LLC)
Publication
F214-021-000  
Medical Payment Guidance
Publication
F248-366-000  
Medical Payment Guidance
Publication
F248-366-000  
Plan Development: What Are My Rights & Responsibilities?
Publication
F280-018-000

World Language(s):
Español  
Plan Development: What Are My Rights & Responsibilities?
Publication
F280-018-000

World Language(s):
Español  
Plan Development: What Are My Rights & Responsibilities?
Publication
F280-018-000

World Language(s):
Español  
Self-Insurer's Bond - Existing Liabilities
Form
F207-068-000  
Stay at Work Exam Room Card
Publication
F243-009-000  
Verification of School Enrollment
Form
F242-055-000

World Language(s):
Español  
Verification of School Enrollment
Form
F242-055-000

World Language(s):
Español  





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