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Application for Special Certificate to Employ at A Subminimum Wage Rate

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



Form
F700-120-000
 
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



Form
F700-122-000
 
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.



Form
F800-031-000

Alt Language(s):
Español
 
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.



Form
F800-042-000

Alt Language(s):
Español
 
Application for Benefits- Crime Victims Spanish - Instrucciones para: Solicitud para Beneficios para Víctimas de Crimen

Instructions in Spanish to complete the English form F800-042-000 Application for Crime Victim benefits. The form is 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. This 12-10 version is internet only.



Form
F800-042-999

Alt Language(s):
Inglés
 
Request for Survivor Counseling Benefits (English/Spanish) Solicitud para Beneficios de Apoyo para los Sobrevivientes  

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



Form
F800-057-909
 
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.



Form
F800-058-000
 
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.



Form
F800-064-000
 
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
 
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.



Form
F800-070-000
 
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.



Publication
F800-074-000
 
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.



Form
F800-076-000
 
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).

Form
F800-080-000
 
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)



Form
F800-081-000
 
Crime Victims Compensation Program Progress Note: Form III

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



Form
F800-082-000
 
Crime Victims Compensation Program Treatment Report: Form IV

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



Form
F800-083-000
 
Safety Comes Thru Job Training
A supervisor having a discussion with his crew. Get poster printing tips.

Poster
FSP0-901-000
 
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.



Poster
FSP0-912-000
 
Caution: Hard Hat Area
Visual reminder of the importance of wearing a hard hat. Get poster printing tips.

Poster
FSP0-928-000

Alt Language(s):
Español
 
Precaución: Obligatorio Usar Casco
Picture of hard hats. Get poster printing tips.

Poster
FSP0-928-999

Alt Language(s):
Inglés
 
Siempre Use Protección para los ojos
Picture of a large eye with some content on when to use eye protection. Get poster printing tips.

Poster
FSP0-940-999

Alt Language(s):
Inglés
 
Always Wear Eye Protection

Sticker: 7.25 inches X 4.25 inches.



Sticker
FSP0-941-000
 
Danger! Minimum Clearance for Counter Balance - Construction

Sticker: 30 inches long.



Sticker
FSP0-974-000
 
Put this Guard Back - 8.5 x 3.5 inches

Sticker: 8.5 inches X 3.5 inches



Sticker
FSP0-993-000

Alt Language(s):
Español
 
Put this Guard Back - 5 1/2 x 2 1/8 inches

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



Sticker
FSP0-993-001

Alt Language(s):
Español
 
 Si usted TIENE que remover este resguardo 8.5 x 5.5

Sticker: 8.5 inches X 3.5 inches



Sticker
FSP0-993-999

Alt Language(s):
Inglés
 
Grinding Wheel - Prevent Accidents

Sticker size 4"x3"



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

Poster
FSP1-004-000

Alt Language(s):
Español
 
Reporte Todas las Lesiones Inmediatamente

Large words: Report All Injuries Promptly. Get poster printing tips.



Poster
FSP1-004-999

Alt Language(s):
Inglés
 
First Aid

Safety Sticker size 5"x6"



Sticker
FSP1-005-000
 
Danger, Workers Above
Picture of workers on a high rise. Get poster printing tips.

Poster
FSP1-012-000

Alt Language(s):
Español
 
Danger, Workers Above-Spanish (Peligro - Trabajadores en el Nivel Superior)

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



Poster
FSP1-012-999

Alt Language(s):
Inglés
 
Danger, Construction Area Authorized Personnel Only
Large words: Danger, Construction Area Authorized Personnel Only. Get poster printing tips.

Poster
FSP1-013-000

Alt Language(s):
Español
 
Peligro - Área en Construcción - Solamente Personas Authorizadas

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



Poster
FSP1-013-999

Alt Language(s):
Inglés
 
Danger
Large lettering: DANGER. Get poster printing tips.

Poster
FSP1-030-000

Alt Language(s):
Español
 
Cartel - PELIGRO

Large lettering: PELIGRO



Poster
FSP1-030-999

Alt Language(s):
Inglés
 
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.

Poster
FSP1-063-000
 
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.



Form
F207-020-111

Alt Language(s):
Español
 
Notificación de Decisión de Cierre para Reclamos Únicamente Médicos para Empleadores Autoasegurados

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.



Form
F207-020-999

Alt Language(s):
Inglés
 
Notificación de Decisión de Cierre para reclamos de Tiempo Perdido para Empleadores Autoasegurados

Used by 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.



Form
F207-070-999

Alt Language(s):
Inglés
 
Notificación de Decisión de Cierre con Discapacidad Parcial Permanente para Empleadores Autoasegurados - 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.



Form
F207-164-999

Alt Language(s):
Inglés
 
Notificación de Decisión de Cierre con Discapacidad Parcial Permanente para Empleadores Autoasegurados - 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.



Form
F207-165-999

Alt Language(s):
Inglés
 
Hearing Services Worker Information

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



Form
F245-049-000
 
Termination of Agreement (Rescission)
To be filled out by the injured worker who wants to return hearing aids.

Form
F245-050-000
 
Independent Medical Exam Comments
Used by the injured worker to provide comments to L&I about their recent medical exam by an IME.

Form
F245-053-000

Alt Language(s):
Español
 
Comentarios Sobre el Exámen Médico Independente
Used by the injured worker to provide comments to L&I about their recent medical exam by an IME.

Form
F245-053-999

Alt Language(s):
Inglés
 
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.



Form
F413-068-000
 
Chemical Hazard Communication: Helpful information for employers (Vietnamese)
Book: Provides employers a checklist on the requirements of the chemical hazard communication rule. Contains an extensive question-and-answer section and information on starting an employee-training program.

Publication
F413-012-555

Alt Language(s):
中国的
Inglés
한국의
Español
 
Request for Cancellation of Program
Used for cancelling an apprenticeship program.

Form
F100-303-000
 
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

Form
F100-510-000
 
Chemical Hazard Communication: Helpful information for employers (Korean)
Book: Provides employers a checklist on the requirements of the chemical hazard communication rule. Contains an extensive question-and-answer section and information on starting an employee-training program.

Publication
F413-012-777

Alt Language(s):
中国的
Inglés
Español
Việt
 
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.



Form
F213-004-000
 
Chemical Hazard Communication: Helpful information for employers (Chinese)
Book: Provides employers a checklist on the requirements of the chemical hazard communication rule. Contains an extensive question-and-answer section and information on starting an employee-training program.

Publication
F413-012-888

Alt Language(s):
Inglés
한국의
Español
Việt
 
Comunicación sobre Peligros Químicos: Información Útil para los Empleadores

Book: Provides employers a checklist on the requirements of the chemical hazard communication rule. Contains an extensive question-and-answer section and information on starting an employee-training program.



Publication
F413-012-999

Alt Language(s):
中国的
Inglés
한국의
Việt
 
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.



Form
F213-005-000
 
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.



Form
F212-224-000

Alt Language(s):
Español
 
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?



Form
F242-109-000

Alt Language(s):
Español
 
Notice of Independent Medical Exam No-Show or Late Cancellation
Notice of Independent Medical Exam No-Show or Late Cancellation

Form
F245-382-000
 
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".



Form
F621-080-000
 





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