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Apprentice Work Progress Record

Worksheets used to record the number of hours worked and Related Supplemental Instruction hours during a registered apprenticeship on a monthly basis. If used, a copy is usually given to the program monthly.



Form
F100-002-000
 
On-The-Job Training Work Hours

Used to report the work hours for an on-the-job training employee.



Form
F100-229-000
 
Using Apprentices on Public Works and Other Projects
Pamphlet: Provides a quick overview of the rules for using apprentices on public works projects, including apprentice utilization. Also describes the benefits of apprenticeship and where to get more information.

Publication
F100-529-000
 
Employers’ Guide to Workers’ Compensation Insurance in Washington State

Book: Explains the Washington State's workers' compensation program. Suggests ways to protect workers' safety and health and describes L&I programs to help employers control premium costs.



Publication
F101-002-000
 
Workplace Posters: Required and Recommended
Fact sheet: Lists posters that Washington State and federal agencies require or recommend employers post in their places of business. The URLs for posters available online and and telephone numbers to request printed posters are also provided. Also includes online resources and contact numbers for state agencies that issue posters.

Poster
F101-054-000
 
What Are Your Rights as a Worker? (English/Russian)
Fact sheet: Provides a brief overview of the worker rights administered by the Department of Labor and Industries. These include certain employment-related rights and rights pertaining to workplace safety and workers' compensation benefits.

Publication
F101-061-404

Alt Language(s):
English/កម្ពុជា
English/한국의
English/Español
English/Việt
 
What Are Your Rights as a Worker? (English/Vietnamese)
Fact sheet: Provides a brief overview of the worker rights administered by the Department of Labor and Industries. These include certain employment-related rights and rights pertaining to workplace safety and workers' compensation benefits.

Publication
F101-061-505

Alt Language(s):
English/កម្ពុជា
English/한국의
English/русский
English/Español
 
What Are Your Rights as a Worker? (English/Cambodian)
Fact sheet: Provides a brief overview of the worker rights administered by the Department of Labor and Industries. These include certain employment-related rights and rights pertaining to workplace safety and workers' compensation benefits.

Publication
F101-061-606

Alt Language(s):
English/한국의
English/русский
English/Español
English/Việt
 
What Are Your Rights as a Worker? (English/Korean)
Fact sheet: Provides a brief overview of the worker rights administered by the Department of Labor and Industries. These include certain employment-related rights and rights pertaining to workplace safety and workers' compensation benefits.

Publication
F101-061-707

Alt Language(s):
English/កម្ពុជា
English/русский
English/Español
English/Việt
 
What Are Your Rights as a Worker?

Fact sheet: Provides a brief overview of the worker rights administered by the Department of Labor and Industries. These include certain employment-related rights and rights pertaining to workplace safety and workers' compensation benefits.



Publication
F101-061-909

Alt Language(s):
English/កម្ពុជា
English/한국의
English/русский
English/Việt
 
If Family Members Work for You, Know Your Obligations (English/Thai)

Fact sheet: Provides an overview and resources to know your obligations when you have family members working for you. Relatives, including children, must be treated as employees with the same rights as any other paid worker in the state of Washington.



Publication
F101-077-303

Alt Language(s):
English/中国的
English/한국의
English/русский
English/Español
English/Việt
 
If Family Members Work for You, Know Your Obligations (English/Russian)
Fact sheet: Provides an overview and resources to know your obligations when you have family members working for you. Relatives, including children, must be treated as employees with the same rights as any other paid worker in the state of Washington.

Publication
F101-077-404

Alt Language(s):
English/中国的
English/한국의
English/Español
English/Thai
English/Việt
 
If Family Members Work for You, Know Your Obligations (English/Vietnamese)
Fact sheet: Provides an overview and resources to know your obligations when you have family members working for you. Relatives, including children, must be treated as employees with the same rights as any other paid worker in the state of Washington.

Publication
F101-077-505

Alt Language(s):
English/中国的
English/한국의
English/русский
English/Español
English/Thai
 
If Family Members Work for You, Know Your Obligations (English/Korean)
Fact sheet: Provides an overview and resources to know your obligations when you have family members working for you. Relatives, including children, must be treated as employees with the same rights as any other paid worker in the state of Washington.

Publication
F101-077-707

Alt Language(s):
English/中国的
English/русский
English/Español
English/Thai
English/Việt
 
If Family Members Work for You, Know Your Obligations (English/Chinese)
Fact sheet: Provides an overview and resources to know your obligations when you have family members working for you. Relatives, including children, must be treated as employees with the same rights as any other paid worker in the state of Washington

Publication
F101-077-808

Alt Language(s):
English/한국의
English/русский
English/Español
English/Thai
English/Việt
 
If Family Members Work for You, Know Your Obligations (English/Spanish) - Conozca sus Obligaciones Cuando Miembros de su Familia Trabajan para Usted

Fact sheet: Provides an overview and resources to know your obligations when you have family members working for you. Relatives, including children, must be treated as employees with the same rights as any other paid worker in the state of Washington.



Publication
F101-077-909

Alt Language(s):
English/中国的
English/한국의
English/русский
English/Thai
English/Việt
 
2008 Annual Report for the Washington State Fund: Washington's State-run Workers' Compensation Program

Book: Introduces Washington State's Workers' Compensation Program, including rate-setting and investment policies, financial statement overview, and services available to help employers control workers' comp costs.



Publication
F101-086-000
 
Protegiendo a los trabajadores de Washington (Protecting Washington Workers)
DVD: An innovative tool to teach Spanish-speaking workers about workplace rights while introducing English terminology.

DVD
F130-004-909
 
Getting Back to Work: It's Your Job and Your Future
Pamphlet/booklet: Briefly explains steps to return to work quickly and minimize the economic impact of time-loss. Also provides helpful resources. Intended for injured workers.

Publication
F200-001-000

Alt Language(s):
Español
 
Getting Back to Work: It's Your Job and Your Future-Spanish (Regresando a Trabajar es su Trabajo y su Futuro)

Pamphlet/booklet: Briefly explains steps to return to work quickly and minimize the economic impact of time-loss. Also provides helpful resources. Intended for injured workers.



Publication
F200-001-999

Alt Language(s):
Inglés
 
Attending Provider's Return-to-Work Desk Reference
Book: Discusses best practices in occupational medicine that help return an injured worker to his/her job as soon as medically possible. Identifies resources available from L&I and explains how to bill for return-to-work services. Three hours of Category 1 CME credit are offered for completing an online self-assessment. Go to www.CMECredits.Lni.wa.gov.

Publication
F200-002-000
 
Employer's Return-to-Work Guide

Pamphlet/booklet: Explains the benefits of 'return to work' from the employer's perspective, describes RTW options, and provides resource and contact information.



Publication
F200-003-000
 
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 (2012)

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 FY2012 (year ending June 30, 2012). Includes narrative about workers' compensation reforms.



Publication
F200-020-000
 
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
 
Agreement of Assumption and Guarantee of Workers' Compensation Liabilities - Application of Certification

Used by an employer to apply for self-insurance.



Form
F207-040-000
 
Agreement of Assumption and Guarantee of Workers' Compensation Liabilities (Certified Self-Insurer)

Used by certified self-insured companies when they are acquired by another organization. New parent organization guarantees the self-insured workers' compensation liabilities of its new subsidiary.



Form
F207-040-001
 
A Guide to Workers' Compensation Benefits For Employees of Self-Insured Businesses

Pamphlet/booklet: Explains to employees of self-insured businesses their rights and responsibilities under industrial insurance law. Describes benefits and how to file a claim.



Publication
F207-085-000

Alt Language(s):
Español
 
Guía de Beneficios de Compensación para los Trabajadores:  Para los Empleados de Empresas Autoaseguradas - (English) A Guide to Workers' Compensation Benefits For Employees of Self-Insured Businesses

Pamfleto/folleto: Explica a los empleados de negocios autoasegurados sus derechos y responsabilidades bajo la ley de seguro industrial.  Describe los beneficios y como  presentar un reclamo.



Publication
F207-085-999

Alt Language(s):
Inglés
 
Transfer of Attending Provider Form for Self Insured Workers

This form is used by self-insured injured workers who want to transfer their medical care.  Self-insured workers should complete the form and send it to their employer or their Third Party Representative.



Form
F207-114-000

Alt Language(s):
Español
 
Transfer of Attending Provider Form for Self Insured Workers Spanish Formulario para Trasferencia de Proveedor Principal para Trabajadores Autoasegurados

This form is used by self-insured injured workers who want to transfer their medical care.  Self-insured workers should complete the form and send it to their employer or their Third Party Representative

Este formulario es utilizado por los trabajadores autoasegurados que desean transferir su cuidado mdico. Los trabajadores autoasegurados deben completar este formulario y enviarlo a su empleador o a su Representante de Terceros.



Form
F207-114-999

Alt Language(s):
Inglés
 
Workers' Compensation Filing Information

Used by only self-insured employers to comply with WAC 296-15-400. The form provides information and instructions to employees of self-insured employers in case of an injury or development of an occupational disease.



Form
F207-155-000

Alt Language(s):
Español
 
Help for Injured Workers of Self-Insured Businesses
Information card: Introduces the Office of the Ombudsman for Self-Insured Injured Workers. The ombudsman is appointed by the Governor to serve as an independent advocate for the rights of injured workers of self-insured employers.

Publication
F207-201-000

Alt Language(s):
Español
 
Help for Injured Workers of Self-Insured Businesses-Spanish (Ayuda para Trabajadores Lesionados de Empresas Autoaseguradas)

Information card: Introduces the Office of the Ombudsman for Self-Insured Injured Workers. The ombudsman is appointed by the Governor to serve as an independent advocate for the rights of injured workers of self-insured employers.



Publication
F207-201-999

Alt Language(s):
Inglés
 
Workers' Compensation Employer's Quarterly Report - SAMPLE ONLY

You must fill out this form quarterly even if you had no workers. These forms are mailed out quarterly to all employers. For instructions on how to complete the Quarterly Report, please refer to F212-239-000 which is available on the internet. This file on the internet is a sample only.



Form
F212-055-000
 
Workers' Compensation Record Keeping and Reporting Guides

Packet: Contains eight quick reference cards covering topics related to workers' compensation record keeping and reporting. Topics include: computering worker hours, standard exception classifications, excluded employments and corporate officers.



Publication
F212-222-000
 
Washington Workers Insured Out-of-State: Employer’s Supplemental Quarterly Report for Workers’ Compensation
The purpose of 212-233-000 Supplemental reporting form is to allow employers to report out-of-state wages and hours as per the requirement in WAC 296-17-25203(8).

Form
F212-233-000
 
Instructions for completing the Workers' Compensation Employer's Quarterly Report

Instructions for completing the Workers' Compensation Employer's Quarterly Report. A sample of the form F212-055-000 is also available on the internet.



Form
F212-239-000
 
QuickFile: Workers' Compensation Quarterly Report Filing Made Easy!

Rack card: Information to help employers file their Workers' compensation quarterly report online. Includes filing webpages links and deadlines.



Publication
F212-244-000
 
Temporary Services Guide to Workers' Compensation Insurance

Used by L&I to assign industrial insurance classifications for workers of temporary help agencies. The first file is a PDF of the Temporary Services Guide to Workers' Compensation Insurance. The second file is a 2003 Excel file. This file is a cross match of non temporary help classifications and the temporary help risk classification associated with that risk class. The third file is a 2003 Excel file. This is a reverse look up for temporary help risk classification and the non temporary classes associated with a temporary help class. File contains an instructions worksheet for the reverse look up worksheet.



Manual
F213-019-000
 
Student Volunteers and Workers' Compensation Coverage
Fact sheet: Covers availability, limitations and cost of Washington State's optional workers' compensation coverage for student volunteers.

Publication
F213-023-000
 
Workers' Compensation Insurance Manual

This manual covers Chapter 296-17 and 296-17A WAC. Topics covered are employer reporting requirements for workers' compensation; employer classification for workers' compensation; and rates and experience rating rules for workers' compensation.



Manual
F213-178-000
 
Computing Worker Hours

Quick reference card: Shows employers how to figure workers' compensation premiums for different types of employees: hourly employees, salaried employees, commissioned personnel or employees paid for piecework. This information is part of the publication, Workers’ Compensation Record Keeping and Report Guides.



Publication
F214-014-000
 
Notice of Completion of Public Works Contract

This is the form used by public agencies to request L&I's approval to release retainage. All contractors are to be listed on the request form with their associated affidavit id number.  Notices received without affidavit id numbers or incomplete information will not be processed and will be returned to the awarding agency. The first EXCEL document is in Office 2007 format. The second file, with the same title, is in Office 2003 format.



Form
F215-038-000
 
Your Workers' Compensation Rate Notice - SAMPLE ONLY

Form used to compute Your Workers' Compensation premiums. Page 2 has rate notice definitions. Sample only.



Form
F225-004-000
 
Settling your L&I claim might be right for you: A new option for injured workers over 55

Pamphlet/booklet: Explains structured settlement and provides an overview of eligibility and the application and approval processes. The audience for this pamphlet is injured workers who might be eligible.



Publication
F240-003-000

Alt Language(s):
Español
 
Settling your L&I claim might be right for you: A new option for injured workers over 55 - Spanish (Llegar a un acuerdo sobre su reclamo de L&I puede ser lo correcto para usted - Una nueva opción para los trabajadores lesionados que tienen más de 55 años de edad)

Pamphlet/booklet: Explains structured settlement and provides an overview of eligibility and the application and approval processes. The audience for this pamphlet is injured workers who might be eligible.



Publication
F240-003-999

Alt Language(s):
Inglés
 
Settling your injured worker's L&I claim: A new option for injured workers over 55

Pamphlet/booklet: Explains structured settlement and provides an overview of eligibility and the application and approval processes. The audience for this pamphlet is employers covered by the state's workers' compensation program. Self-insured employers should read Publication F240-005-000.



Publication
F240-004-000
 
Structured Settlement Income and Expense Worksheet

This form is completed by the injured worker, or their representative in conjunction with an Application for Structured Settlement.



Form
F240-007-000
 
Worker Verification Form

Completed by the injured worker if they are unable to work due to a workplace injury AND their employer is not paying their full wages.

 



Form
F242-052-000

Alt Language(s):
Español
 
Worker Verification Form - Spanish Formulario de Verificación de Empleo

El trabajador lesionado debe completarlo si no puede trabajar debido a una lesión en el lugar de trabajo Y su empleador no le está pagando su salario completo.  



Form
F242-052-999

Alt Language(s):
Inglés
 
Occupational Disease Work History - Continuation

This is a continuation page to the Occupational Disease Work History (F242-071-000) to add additional work history.



Form
F242-071-111

Alt Language(s):
Español
 
Workers' Compensation Benefits: A Guide for Injured Workers

Pamphlet/booklet: For workers covered by L&I (the State Fund). Describes benefits if you have a work-related injury or illness and how to file a claim. Explains a worker's rights and responsibilities under Washington State's industrial insurance law. Note: Previously titled, Workers' Guide to Industrial Insurance Benefits.



Publication
F242-104-000

Alt Language(s):
Español
 
Beneficios de Compensación para los Trabajadores: Una guía para los Trabajadores Lesionados - English (Workers' Compensation Benefits: A Guide for Injured Workers)

Folleto: Explica los derechos y responsabilidades de los trabajadores bajo la ley de seguro industrial.  Describe beneficios y cómo presentar un reclamo.  Aviso: Anteriormente titulado, Guía de Beneficios del Seguro Industrial para los Trabajadores.  



Publication
F242-104-999

Alt Language(s):
Inglés
 
Report of Accident (ROA) Workplace Injury, Accident or Occupational Disease

This form is not available online. If you are an injured worker, ask your medical provider for a copy of this form or you can complete your portion of the Report of Accident (ROA) online at https://secure.Lni.wa.gov/home.

Medical providers can order the ROA and the worker instruction in Spanish from the L&I Warehouse by using the link below.
http://www.Lni.wa.gov/ClaimsIns/Providers/FormPub/ROA/OrderROA.asp



Form
F242-130-000

Alt Language(s):
Español
 
Declaration of Entitlement for Dependent of Deceased Worker Benefits Under Industrial Insurance
Used by a dependent of a worker whose death was related to an on the job injury or accident. This form must be completed, signed, notarized and returned to L&I within 30 days for non interruption of benefits.

Form
F242-173-333

Alt Language(s):
Español
 
Declaration of Entitlement for Totally Disabled Worker Benefits Under Industrial Insurance
Used by a totally permanently disabled worker. This form must be completed, signed, notarized and returned to L&I within 30 days for non interruption of benefits.

Form
F242-173-444

Alt Language(s):
Español
 
Pension and Survivor Benefits in Washington State's Workers' Compensation Program--English/Spanish (Beneficios de Pensión y para Sobrevivientes del Programa de Compensacin para Trabajadores de Washington)

Pamphlet/booket: Answers the most common questions about pension and survivor benefits under Washington's workers' compensation program.



Publication
F242-352-909
 
Address Change Request for Injured Workers
Completed and signed by a State Fund injured worker to notify L&I of a change in address. All address changes must be submitted in writing and signed by the injured worker.

Form
F242-388-000

Alt Language(s):
Español
 
Address Change Request for Injured Workers - (Spanish) Solicitud para Cambio de Direccion para Trabajadores Lesionados

Completed and signed by a State Fund injured worker to notify L&I of a change in address. All address changes must be submitted in writing and signed by the injured worker.



Form
F242-388-999

Alt Language(s):
Inglés
 
Preauthorization Request for Services for State Fund Workers' Compensation Patients

This form can only be used for services that can be authorized by the claim manager and it should not be used for Utilization Review (Qualis), Provider Hotline or requests to the Occupational Nurse Consultant.  If you are unsure of what services need to be authorized see L&I fee lookup utility at www.Lni.wa.gov/apps/FeeSchedules/

For complete information on all authorization processes please see:  www.Lni.wa.gov/ClaimsIns/Providers/AuthRef/GetAuth.asp



Form
F242-397-000
 
FileFast postcard handout for workers
Handout (4.25 x 6): Explains to workers why and how to file an accident report online or by phone following an injury; also reminds them to stay in contact with employer and L&I.

Publication
F242-398-000
 
FileFast poster for workers
Poster (8.5 x 11): Explains to workers why and how to file an accident report online or by phone following an injury and reminds them to stay in contact with employer and L&I.

Poster
F242-399-000
 
FileFast wallet card for workers
Wallet card (3.5 x 2): Reminds workers of FileFast web address and number for call center.

Publication
F242-400-000
 
3 Things to Know about L&I's Medical Provider Network

Handout: Explains to workers the basic information about L&I’s Medical Provider Network. The handout can be used with workers covered both by L&I and by self-insured employers. Applies to workers in Washington state. Includes website and phone number contact information.



Publication
F242-406-000

Alt Language(s):
Español
 
3 Things to Know About L&I's Medical Provider Network - Spanish (3 Cosas que Debe Conocer Sobre la Red de Proveedores Médicos de L&I)

 

Handout: Explains to workers the basic information about L&I’s Medical Provider Network. The handout can be used with workers covered both by L&I and by self-insured employers. Applies to workers in Washington state. Includes website and phone number contact information.

 



Publication
F242-406-999

Alt Language(s):
Inglés
 
Stay at Work Wage Reimbursement Application for Employers

Employer of record can request reimbursement for wages paid to an injured worker during light duty or transitional work. After completing the form, the employer submits it, along with supporting documentation, to the Stay at Work program for review and approval. For expense reimbursements see F243-003-000.



Form
F243-001-000
 
Stay at Work Expense Reimbursement Application for Employers Tools, Clothing, Training.

Employer of record can request reimbursement for tools, clothing, or training expenses required to enable an injured worker to return to light duty or transitional work. After completing the form, the employer submits it, along with supporting documentation, to the Stay at Work program for review and approval. For wage reimbursements see F243-001-000.



Form
F243-003-000
 
Complete Stay at Work Guide for Employers, The

Booklet: Explains Stay at Work, a financial incentive program that encourages Washington employers to find light-duty or transitional jobs for workers recovering from on-the-job injuries. Provides information on reimbursements, what is covered and how to apply. Detailed Q&A section included.



Publication
F243-005-000
 
Stay at Work: A new program to help employers keep injured workers on the job--pays half the wage plus expenses

Pamphlet/booklet: Provides an overview Stay at Work, a financial incentive program that encourages Washington employers to find light-duty or transitional jobs for workers recovering from on-the-job injuries. Includes information on eligibility, how to apply, and where to get more information.



Publication
F243-006-000

Alt Language(s):
Español
 
Stay at Work: A new program to help employers keep injured workers on the job--pays half the wage plus expenses (Permanezca en el Trabajo: Una Solución Factible -- Un programa para ayudar a los empleadores a mantener a los trabajadores lesionados en el trabajo -- paga la mitad del salario base además de otros gastos).

Pamphlet/booklet: Provides an overview Stay at Work, a financial incentive program that encourages Washington employers to find light-duty or transitional jobs for workers recovering from on-the-job injuries. Includes information on eligibility, how to apply, and where to get more information.



Publication
F243-006-999

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
 
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.)
Filled out by the provider when they treat an injured worker. See web links below for: Latest payment amounts, Updates and corrections, and Review payment policy. For use in place of Minimum Data Set (MDS) 3.0 beginning October 1, 2010.

Form
F245-392-000
 
Provider Network Agreement
The provider network agreement for participation in the health care provider network for injured workers covered by Washington State Fund and self-insured employers.

Form
F245-397-000
 
Non-Network Provider Application

Includes the F248-036-000 Statewide Payee Registration and W-9 form. For providers to complete that do not want to become a Labor and Industries network provider, or for a specialty that L&I is not accepting network applications for at this time. If you are applying to be a Labor and Industries network provider, please complete application process at www.ProviderNetwork.Lni.wa.gov



Form
F248-011-000
 
Third Party Recovery Worksheet

Used by third party attorneys to calculate distribution of proposed settlements in third party claims.



Form
F249-006-111
 
Doctor's Worksheet for Rating Dorso-Lumbar & Lumbo-Sacral Impairment
This worksheet is to help the attending physician perform impairment rating on their patients with permanent partial disability of the Dorso-Lumbar or Lumbo-Sacral spine.

Form
F252-006-000
 
Hearing Impairment Calculation Worksheet
Used by the attending doctor to determine hearing loss.

Form
F252-007-000
 
Doctor's Worksheet for Rating Cervical and Cervico-Dorsal Impairment
Doctor's Worksheet for Rating Cervical and Cervico-Dorsal Impairment

Form
F252-056-000
 
Home Modification for Workers with Catastrophic Injuries

Fact sheet: Answers questions about the home modification benefit in Washington State's workers' compensation program, who qualifies, what L&I can pay, and where to get more information.



Publication
F252-060-000
 
Home Modification for Workers with Catastrophic Injuries - Questions and Answers for Contractors

Fact sheet: Answers questions about the home modification benefit in Washington State's workers' compensation program and the bid process for contractors interested in this work.



Publication
F252-061-000
 
L&I Benefits for Workers Who Are Terminally Ill

Answers questions persons with a terminal illness may ask about benefits from L&I.



Publication
F252-094-000
 
Targeting Fraud and Abuse in Washington State's Workers' Compensation Program: 2008 Report to the Legislature
Booklet/Pamphlet: Provides an overview of L&I's activities to deter and detect workers' compensation fraud and abuse by workers, employers and medical providers. Includes statistics on dollars collected and costs avoided.

Publication
F262-032-000
 
Targeting Fraud and Abuse in Washington State's Workers' Compensation Program: 2009 Report to the Legislature
Booklet/Pamphlet: Provides an overview of L&I's activities to deter and detect workers' compensation fraud and abuse by workers, employers and medical providers. Includes statistics on dollars collected and costs avoided for fiscal year 2009.

Publication
F262-034-000
 
Stop Work Payroll Report
Stop Work Payroll Report

Form
F262-043-000
 
Targeting Fraud and Abuse in Washington State's Workers' Compensation Program: 2010 Report to the Legislature
Booklet/Pamphlet: Provides an overview of L&I's activities to deter and detect workers' compensation fraud and abuse by workers, employers and medical providers. Includes statistics on dollars collected and costs avoided for fiscal year 2010.

Publication
F262-044-000
 
Workers' Compensation Discrimination-English/Spanish (Discriminación porque se lesionó en su trabajo)
Fact sheet: Explains workers' legal right to file a workplace injury claim and how to file a complaint if discrimination has occurred.

Publication
F262-249-909
 
Targeting Fraud and Abuse in Washington State's Worker's Compensation Program: 2005 Report to the Legislature
Booklet/pamphlet: Provides an overview of L&I's activities to deter and detect workers' compensation fraud and abuse by workers, employers and medical providers. Includes statistics on dollars collected and costs avoided.

Publication
F262-251-000
 
Avoid Liability for Your Subcontractor's Unpaid Workers' Comp Premiums
Fact sheet: Tells construction contractors how to protect themselves from liability for their subcontractor's unpaid workers' compensation premiums.

Publication
F262-262-000

Alt Language(s):
Español
 
Targeting Fraud and Abuse in Washington State's Workers Compensation Program: 2006 Report to the Legislature
Booklet/pamphlet: Provides an overview of L&I's activities to deter and detect workers' compensation fraud and abuse by workers, employers and medical providers. Includes statistics on dollars collected and costs avoided.

Publication
F262-276-000
 
Workers' Comp Fraud Hurts YOU
Pamphlet: Explains the impacts of workers' comp fraud and L&I's efforts to prevent and find fraud by workers, employers, contractors, and medical providers.

Publication
F262-279-000
 
Targeting Fraud and Abuse in Washington State's Workers' Compensation Program: 2007 Report to the Legislature
Booklet/Pamphlet: Provides an overview of L&I's activities to deter and detect workers' compensation fraud and abuse by workers, employers and medical providers. Includes statistics on dollars collected and costs avoided.

Publication
F262-280-000
 
Intent to Hire Preferred Worker
Used by employers when hiring a preferred worker. This form must be received within 60 days of the hiring and the Preferred Worker Employer's Job Description (F280-022-000) form must be attached.

Form
F280-010-000
 
Intent to Hire Preferred Worker with Developmental Disabilities
Used by employers rehiring developmentally disabled workers after an industrial injury. This form requests preferred worker status and shows the physical demands of the work to be performed by the worker. The Preferred Worker Employer's Job Description (F280-022-000) should be attached.

Form
F280-011-000
 
Assessing Your Ability to Work: Your Rights and Responsibilities
Booklet: Explains the basics of the assessment phase of vocational services to injured workers. L&I sends this booklet to injured workers when they are referred for assessment services.

Publication
F280-017-000

Alt Language(s):
Español
 
Assessing Your Ability to Work: Your Rights and Responsibilities -- Spanish (Evaluando su Capacidad para Trabajar: Sus Derechos y Responsabilidades, Servicios de Rehabilitación Vocacional)

Booklet: Explains the basics of the assessment phase of vocational services to injured workers. L&I sends this booklet to injured workers when they are referred for assessment services.



Publication
F280-017-999

Alt Language(s):
Inglés
 
Preferred Worker Program

Pamphlet/booklet: Describes the Preferred Worker Program and the benefits employers receive when hiring a preferred workers. Iin general, these are workers whose work-related injury or occupational disease prevents them from returning to their old job.



Publication
F280-021-000

Alt Language(s):
Español
 
Preferred Worker Program-Spanish (Programa con Incentivos para Reemplear Trabajadores Lesionados)

Pamphlet/booklet: Describes the Preferred Worker Program and the benefits employers receive when hiring a preferred workers. In general, these are workers whose work-related injury or occupational disease prevents them from returning to their old job.



Publication
F280-021-999

Alt Language(s):
Inglés
 
Preferred Worker Employers Job Decsription
Used by the employer to describe the job for the preferred worker. This form is reviewed by a vocational services consultant to ensure that the offered job is consistent with the worker's medical restrictions.

Form
F280-022-000
 
Request for Preferred Workers Status

Used by vocational providers to apply for preferred worker status on behalf of an industrially injured worker.



Form
F280-023-000
 
Vocational Questionnaire/Work History

Vocational Questionnaire/Work History for use by Vocational Providers serving injured workers.



Form
F280-038-000

Alt Language(s):
Español
 
Vocational Questionnaire/Work History - Spansih CUESTIONARIO VOCACIONAL/HISTORIA DE TRABAJO

Vocational Questionnaire/Work History for use by Vocational Providers serving injured workers



Form
F280-038-999
 
On-The-Job Training (OJT) Worksheet for Vocational Providers

On-The-Job Training (OJT) Worksheet for Vocational Providers



Form
F280-039-000
 
Referral for WorkSource Services from Private Vocational Provider

Used by private Vocational Providers to refer injured workers to WorkSource



Form
F280-046-000
 
Preferred Worker Benefit Frequently Asked Questions

Fact sheet: Includes information regarding the benefits of Preferred Worker certification, answers to questions frequently asked by workers, phone and website contacts.



Publication
F280-052-000

Alt Language(s):
Español
 
Preferred Worker Benefit Frequently Asked Questions - Spanish (Preguntas frecuentes sobre el Beneficio del Programa de Incentivos para Volver a Emplear Trabajadores Lesionados)

Fact sheet: Includes information regarding the benefits of Perferred Worker certification, answers to questions frequently asked by workers, phone and website contacts.



Publication
F280-052-999

Alt Language(s):
Inglés
 
Workers' Guide to Hazardous Chemicals: Understanding the Right-to-Know Law-English/Spanish (Gua del trabajador para el uso de qumicos peligrosos: Comprendiendo la Ley del derecho a saber)
Pamphlet/booklet: Explains Washington's chemical hazard communication standard, which requires employers to inform their employees about hazardous chemicals in the workplace and to train them in their proper use.

Publication
F413-014-909
 
Protecting Yourself and Your Workers from Poison Oak and Ivy (English/Spanish)
Pamphlet/booklet: Discusses the effects of poison oak and ivy, where it is found in Washington State, how to control growth and protect workers from exposure.

Publication
F413-047-000
 
Working Safely with Asbestos in Brake and Clutch Linings
Pamphlet/booklet: Reviews the health hazards of asbestos exposure, use of asbestos in brake and clutch linings, employer's responsibilities, how employees can protect themselves, employee rights, and where to get help with waste management.

Poster
F413-049-000
 
Your Lungs, Your Work, Your Life: What You Should Know about Work-related Asthma

Pamphlet/booklet: Briefly reviews the symptoms and causes of work-related asthma and explains prevention and treatment approaches.



Publication
F413-060-000

Alt Language(s):
русский
Español
 
Your Lungs, Your Work, Your Life: What You Should Know about Work-related Asthma (Russian)
Pamphlet/booklet: Briefly reviews the symptoms and causes of work-related asthma and explains prevention and treatment approaches.

Publication
F413-060-444

Alt Language(s):
Inglés
Español
 
Worker and Community Right-to-Know Program
Fact sheet: Provides an overview of the Worker and Community Right-to-Know (RTK) Program authorized by legislation in 1986. Explains the RTK fees, education on hazardous substances that the fees support, who pays the fees and how they are calculated.

Publication
F413-075-000
 
Sawmillis & Woodworking Operations WAC 296-78

The Department of Labor and Industries has rewritten and reorganized for clarity and ease of use, Chapter 296-78 WAC, Sawmills and Woodworking Operations.



Manual
F414-010-000
 
Chapter 296-45 WAC - Safety Standards for Electrical Workers

Safety Standards for Electrical Workers, 296-45 WAC, consist of the requirements for safeguarding employees against electrical hazards in their workplace; requirements for electric equipment and wiring in locations classified as hazardous.



Manual
F414-032-000
 
Safety Standards for Construction Work WAC 296-155

Construction work shall mean and include all or any part of excavation, construction, erection, alteration, repair, demolition, and dismantling, of buildings and other structures.



Manual
F414-033-000
 
Workplace Safety and Health Rules and Guides

CD: Contains workplace safety and health rules for Washington State and links to policies and related laws. Also contains guides covering accident prevention programs (APP) and personal protective equipment (PPE). Note: Order CD or view rules online.



CD
F414-074-034
 
Safety and Health Workshops

Pamphlet/Brochure: Introduces free workshops to help employers prevent workplace injuries and control workers' compensation costs. Includes course descriptions, and how to register.



Publication
F416-036-000
 
Mobile Cranes/Derricks Worksheet for Construction Industry

Mobile Cranes/Derricks Worksheet for Construction Industry



Form
F416-043-000
 
Cranes, Derricks and Material Handling Devices Worksheet for Maritime Industry

Use this form for the inspection of cranes, derricks and materials handling devices on waterfront operations



Form
F416-051-000
 
A Guide to Workplace Safety and Health in Washington State

Pamphlet/booklet: Provides an overview of the Washington Industrial Safety and Health Act (WISHA), worker and employer rights and responsibilities, enforcement of WISHA rules, and consultation and education services L&I provides. Previously titled A Guide to WISHA



Publication
F416-132-000

Alt Language(s):
Español
 
A Guide to Workplace Safety and Health in Washington State-Spanish (Una Guía de Seguridad y Salud del Lugar de Trabajo en el Estado de Washington)

Pamphlet/booklet: Provides an overview of the Washington Industrial Safety and Health Act (WISHA), worker and employer rights and responsibilities, enforcement of WISHA rules, and consultation and education services L&I provides. Previously titled A Guide to WISHA



Publication
F416-132-999

Alt Language(s):
Inglés
 
Overhead Crane Bridge, Monorail, Gantry Worksheet for Construction
Overhead Crane Bridge, Monorail, Gantry Worksheet for Construction.

Form
F416-141-000
 
Fall Protection Work Plan Requirements

This booklet defines the work plan requirements you must meet for fall protection.



Form
F417-107-000
 
Office Ergonomics: Practical solutions for a safer workplace
Book: Provides information and tools to analyze office jobs, find problems and develop ergonomic solutions.

Publication
F417-133-000
 
Workplace Violence: Awareness and Prevention for Employers and Employees
Book: Describes four types of workplace violence, outlines steps to minimize and prevent violent acts, and discusses potential risk factors and prevention techniques.

Publication
F417-140-000
 
Safety and Health Discrimination in the Workplace (English/Spanish)/ Discriminación de seguridad y salud en el lugar de trabajo

Poster: Employees have the right to report concerns about safety and health in their workplace. This poster describes "protected activities" under the Washington Industrial Safety and Health Act (WISHA) and explains what an employee should do if he/she has been punished or fired for exercising these rights. Get poster printing tips.



Poster
F417-188-909
 
Keep Your Employees Safe and Working

Pamphlet/booklet: Describes the benefits of free employer consultations offered by L&I's Division of Occupational Safety and Health (DOSH). These services include on-site safety and/or industrial hygiene consultations, ergonomics assistance and risk management advice.



Publication
F417-209-000

Alt Language(s):
Español
 
Keep Your Employees Safe and Working - Spanish (Mantenga a sus empleados seguros y trabajando)

Pamphlet/booklet: Describes the benefits of free employer consultations offered by L&I's Division of Occupational Safety and Health (DOSH). These services include on-site safety and/or industrial hygiene consultations, ergonomics assistance and risk management advice.



Publication
F417-209-999

Alt Language(s):
Inglés
 
A Safe and Healthy Workplace Begins with You
Pamphlet: Provides an overview of employers' responsibilities for workplace safety and health in Washington State. Covers free L&I services, including workplace consultations, online training and prevention resources and required posters. Intended for new businesses or businesses hiring employees for the first time.

Publication
F417-210-000
 
Safety and Health Program Assessment Worksheet

Safety and Health Program Assessment Worksheet



Form
F417-227-000
 
When a Loved One Dies at Work

Brochure: Provides information to loved ones of workers who died from a job-related injury or illness, including how to apply for survivor benefits. Explains the L&I fatality investigation and how family members can stay informed of the investigation's status.



Publication
F417-240-000

Alt Language(s):
Español
 
When a Loved One Dies at Work - Spanish (Cuando un ser querido fallece en el lugar de trabajo)

Brochure: Provides information to loved ones of workers who died from a job-related injury or illness, including how to apply for survivor benefits. Explains the L&I fatality investigation and how family members can stay informed of the investigation's status.



Publication
F417-240-999

Alt Language(s):
Inglés
 
Workplace Safety and Health Pocket Guide

Pocket guide: Provides links to online information, including safety and health consultations, how to develop a safety program, reporting hazards and injuries, other safety training, and information for teen workers.



Publication
F417-241-000
 
Safety and Health Discrimination in the Workplace

Brochure: Employees have the right to report concerns about safety and health in their workplace. This brochure describes "protected activities" under the Washington Industrial Safety and Health Act (WISHA) and explains what an employee should do if he/she has been punished or fired for exercising these rights.



Publication
F417-244-000

Alt Language(s):
Español
 
Discriminación de seguridad y salud en el lugar de trabajo (Safety and Health Discrimination in the Workplace)

Folleto: Los empleados tienen derecho a reportar sus inquietudes sobre seguridad y salud en sus lugares de trabajo.  Este folleto describe las “actividades protegidas": bajo la Ley de Seguridad y Salud Industrial de Washington (WISHA, por su sigla en inglés) y explica lo que debe hacer un empleado si él/ella es castigado o despedido por ejercer estos derechos.



Publication
F417-244-999

Alt Language(s):
Inglés
 
2014 Workplace Safety and Health Calendar: Top 12 Hazards that Cause Injuries and Deaths

Calendar: Features real Washington State businesses and employees handling typical workplace hazards and spotlighting the top 12 hazards that cause injuries and deaths. It includes suggested weekly safety and health tips for different hazards, including slips trips and falls, struck by falling objects, burns and more.



Publication
F417-248-000
 
Hazard Documentation Worksheet
Hazard Documentation Worksheet for use by L&I compliance staff to describe, measure and comment on workplace hazards.

Form
F418-031-000
 
Electrical Work on Residential Property: What You Should Know Before Work Begins
Fact Sheet: Explains to property owners the importance of electrical permits, inspections and approvals. An electrical permit is required for most new, remodel and maintenance electrical work.

Publication
F500-078-000
 
Contractor Electrical Work Permit Application

This application is used to apply for a valid electrical permit from L&I. 4 pages.



Form
F500-093-000
 
Property Owner Electrical Work Permit Application

This application is used to apply for a valid electrical permit. 5 pages.



Form
F500-094-000
 
Electrical Work on Commercial Property: What You Should Know Before Work Begins
Fact Sheet: Explains to commercial property owners the importance of electrical permits, inspections and approvals. An electrical permit is required for most new, remodel and maintenance electrical work.

Publication
F500-109-000
 
Before Electrical Sign Work Begins: What Electrical Sign Contractors and Electricians Should Know
Fact Sheet: Explains work that is allowed and not allowed under (04) Sign Scope of Work and what electrical sign contractors and electricians should know before doing sign work. Also covers electrical Class B labels and electrical permits, inspections and fees.

Publication
F500-111-000
 
Green Power Generation System Installation: What You Should Know Before Doing Any Electrical Work
Fact sheet: Explains that an electrical permit and inspection are required for most new, remodel, and maintenance electrical work. Provides information specific to the installation of green power generation systems.

Publication
F500-116-000
 
An Annual Electrical Permits Saves Time and Money. Would it Work for You?

Flier: Describes when facility operators/owners qualify for an annual electrical permit.



Publication
F500-123-000
 
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
 
Protect My Home Hire Smart Worksheet

Checklist: Provides information to help screen potential contractors for home construction or repair/remodel projects. Presented in an organized, step-by-step format.



Publication
F625-111-000
 
Affidavit of Wages Paid - Public Works Contract and Instructions

This form is a fillable Word document that is used by a contractor, company or agency to show the wages paid to employees on a public works project. The best way to use this document is to bookmark this page as a “Favorite” in your web browser. Then each time when you want to use the document, access the online version of the form. This will ensure you are always utilizing the most recently published form. (We recommend you not download the document and save the form for future use because we may make changes to the form that your downloaded version will not contain.) You must file the Affidavit of Wages Paid form when you have completed your portion of a public works job/project. Addendum A is form number F700-161-000, Addendum C is form number F700-162-000, and the EHB 2805 (RCW 39.04.370) Addendum is form number F700-164-000.



Form
F700-007-000
 
Operating Power Lawn and Yard-care Equipment: Safety for Teen Workers
Fact sheet: Overview of safety practices, plus information on what equipment employees under 18 can and cannot operate. Provides resources on requirements for hearing protection and PPE (personal protective equipment).

Publication
F700-010-000
 
Teens at Work: Facts for Employers, Parents and Teens

Pamphlet/booklet: Answers questions employers, parents and teens may have about employing teen workers (ages 14-17). Explains non-agriculture work rules, including the necessary permits, hours and work conditions. Provides links to other resources.



Publication
F700-022-000

Alt Language(s):
Español
 
Teens at Work: Facts for Employers, Parents and Teens /Adolescentes en el trabajo (Spanish)

Pamphlet/booklet: Answers questions employers, parents and teens may have about employing teen workers (ages 14-17). Explains non-agriculture work rules, including the necessary permits, hours and work conditions. Provides links to other resources.



Publication
F700-022-999

Alt Language(s):
Inglés
 
Statement of Intent to Pay Prevailing Wages - Public Works Contract

This form is a fillable Word document that is used by a contractor, company or agency upon accepting work on a public works project. The best way to use this use this document is to bookmark this page as a “Favorite” in your web browser. Then each time when you want to use the document, access the online version of the form. This will ensure you are always utilizing the most recently published form. (We recommend you not download the document and save it for future use because we may make changes to the form that your downloaded version will not contain.) You should file this form immediately after the contract is awarded and before you begin work. Form number F700-160-000 is addendum A and F700-163-000 is addendum C.



Form
F700-029-000
 
Agreement - Farm Labor Contractors and Workers

Employment wages and conditions agreement with Farm Labor Contractors and Workers



Form
F700-046-000

Alt Language(s):
Español
 
Agreement - Farm Labor Contractors and Workers - Spanish - Acuerdo entre Contratistas Agrícolas y Trabajadores

Employment wages and conditions agreement with Farm Labor Contractors and Workers



Form
F700-046-999

Alt Language(s):
Inglés
 
What Are Your Rights when You Work for a Farm Labor Contractor? (English/Spanish) / ¿Cúales son sus derechos cuando trabaja para un contratista de trabajadores agrícolas?

Fact sheet: Provides an overview of rights workers have when they are employed by a farm labor contractor. Several topics are covered, including regular wages, workplace safety, and help if injured on the job.



Publication
F700-067-000
 
What Are Your Rights When You Work for a Farm Labor Contractor? (English/Spanish) / ¿Cúales son sus derechos cuando trabaja para un contratista de trabajadores agrícolas?
Fact sheet: Explains workers' rights when they are employed by a farm labor contractor. Topics covered include workplace safety, rest and meal breaks, and help if injured on the job.

Publication
F700-067-909
 
Your Rights as a Worker in Washington State/ Sus Derechos como Trabajador en el Estado de Washington (English/Spanish)

Required poster: Reviews workers' rights under Washington's wage-and-hour laws. Topics include minimum wage, overtime, meal and rest breaks, pay periods, deductions, and employment of teens under age 18. Also reviews family leave provisions under federal and state law, and leave for spouses of deploying military personnel and victims of domestic violence. Note: Employers in both agricultural and non-agricultural industries in Washington State must display this poster where workers can see it.

Please order from L&I or print on 11" x 17" paper.

Get poster printing tips.



Poster
F700-074-909
 
Young Workers in Agriculture/Trabajadores jóvenes en la agricultura (English/Spanish)

Pamphlet/booklet: Answers many questions employers and minor workers have about employing minors. Covers agriculture work rules, including the necessary permits, hours and work conditions for workers 12-17 years of age.



Publication
F700-096-909
 
Agricultural workers information line (English/Spanish)
Card: Wallet card with a toll-free telephone number where agricultural workers can call to learn about their workplace rights.

Publication
F700-103-909
 
Your Daily Record of Hours Worked (English/Spanish) / Su Registro de Horas Trabajadas
Pamphlet/booklet: A pocket-sized bilingual booklet to encourage agricultural workers to keep track of their daily work hours and earnings.

Publication
F700-105-909
 
Employer Petition to The Court for Minor Work Permit Under Age 14

Petition to The Court for Minor Work Permit Under Age 14 by Employer.



Form
F700-118-000
 
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
 
Agricultural Employer Worksheet

Used by agricultural employers to assist them in determining if they are following the state Agricultural Employment Standards and the Minimum Wage Act for their employees.



Form
F700-125-000
 
Sports Teams and Youth Workers

Fact sheet: Explains the requirements for sports organizations that engage young people as volunteers or employees to referee, assist or work for the organizations. The focus is workers' compensation coverage and minor work rules.



Publication
F700-130-000
 
Affidavit of Wages Paid Addendum B List of Next Tier Subcontractors - Public Works Contract

Copies of the 05-2008 version will be available in the warehouse later in July.



Form
F700-143-000
 
Worker Rights Complaint Form

This is the Worker Rights Complaint Form. Both the 12-2011 and 10-2010 versions are valid.



Form
F700-148-000

Alt Language(s):
Español
 
Worker Right Complaint Form (Spanish) Formulario de Queja sobre los Derechos Laborales

Worker Rights Complaint Form. Both the 10-2010 and 12-2011 versions are valid.



Form
F700-148-999

Alt Language(s):
Inglés
 
Plain Talk Summary of Prevailing Wage Laws: Understand Your Responsibilities and Rights When Performing Public Work - Spanish (Resumen de las Leyes de Salario Prevaleciente en Lenguaje Sencillo Entienda sus Responsabilidades y Derechos al Hacer Trabajos Públicos)

8.5" X 11" sheets: Provides a summary of prevailing wage laws and rules in Spanish. This publication is only available in Spanish. For similar information in English, read the Washington State Prevailing Wage Law booklet.



Publication
F700-152-999
 
What You Need to Know if You Don't Get Paid: A Worker's Guide to the Washington State Wage Payment Act-English/Spanish (Lo que necesita saber si no recibe su pago: Una guía para el trabajador de la ley del pago de salario del) estado de Washington
Fact sheet: Summarizes workers' rights and responsibilities regarding minimum wage, pay, work hours and overtime and explains how to file a wage complaint. Includes answers to several commonly asked questions.

Publication
F700-153-909
 
Employing teens under 18 in food service? - L&I’s fact sheet of permitted and prohibited work activities for youth ages 14 to 17 in food service

Fact sheet: Explains permitted and prohibited work activities for youth ages 14 to 17 in food service. Includes rules for driving, student-learner exemptions and work hours.



Publication
F700-167-000
 
Parent Authorization Summer Work

This form is for summer employment of minors, only, and is for parents or legal guardians to approve the hours and work activities for a minor employee to work according to terms listed by the employer.  All parties must sign to approve the work schedule and duties for a minor prior to permitting them to work.  This is NOT a work permit.  Employers must obtain a minor work permit endorsement on their Business License where they employ workers under 18.



Form
F700-168-000
 
Your Daily Record of Hours and Units Worked - For Agricultural Workers / Spanish - Su Registro Diario de Horas y Unidades Trabajadas - Para Trabajadores Agrícolas

Booklet: A pocket-sized bilingual guide to encourage agricultural workers to keep track of their daily work hours, units and earnings.



Publication
F700-169-909
 
Crime Victim Worker Verification - Spanish - Formulario de Verificación de Empleo

Crime Victim Worker Verification - Spanish - Formulario de Verificación de Empleo



Form
F800-110-999

Alt Language(s):
Inglés
 
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
 
Authorization to Release Claim Information

Used by the worker to designate a person(s) as an authorized representative for the worker's claim. An authorized representative can access claim information.



Form
F101-010-000

Alt Language(s):
Español
 
Request for Claim Information

Used by workers, workers' representatives, employers or employers' representatives to request claim information from L&I.



Form
F101-010-111
 
Autorización para Proveer Información de Reclamos

Used by the worker to designate a person(s) as an authorized representative for the worker's claim. An authorized representative can access claim information.



Form
F101-010-999

Alt Language(s):
Inglés
 
Independent Contractor Guide: A Step-by-Step Guide to Hiring Independent Contractors in Washington State

Pamphlet/booklet: A step-by-step guide to hiring independent contractors in Washington State. This publication is a general guide to help you understand how and when the Department of Labor & Industries applies workers’ compensation laws to independent contractors.



Publication
F101-063-000

Alt Language(s):
Español
 
Guía para Contratar Contratistas Independientes en el Estado de Washington

Pamphlet/booklet: Designed to help employers determine if their workers are employees or independents under Washington's workers' compensation, workplace safety, wage and hour and unemployment tax laws. Includes a short "test" and helpful references.



Publication
F101-063-999

Alt Language(s):
Inglés
 
Applying for Your Washington Business License: A Step-by-Step Guide
Pamphlet: Concise, easy-to-read pamphlet that explains the steps to apply for a business license and what to do if you plan to employ workers. Includes how to apply to be a registered construction contractor.

Publication
F101-079-000

Alt Language(s):
Español
 
Aplicando para su Licencia de Negocio en Washington: Una Guía Detallada

Pamphlet: Concise, easy-to-read pamphlet that explains the steps to apply for a business license and what to do if you plan to employ workers. Includes how to apply to be a registered construction contractor.



Publication
F101-079-999

Alt Language(s):
Inglés
 
Plan for and Pay Your Taxes
Information card: Introduces Washington State's 28-minute DVD that covers state business taxes and workers' compensation premiums and provides information on how to file.

Publication
F101-091-000
 
Plan for and Pay Your Taxes DVD

DVD: Covers state business taxes and workers' compensation premiums and provides information on how to file. This 28-minute DVD can help employers plan ahead and obtain more information.



DVD
F101-091-034
 
An Employer's Intro to L&I

Info card: Provides information on the Employer's Intro to L&I workshop, including statewide schedule of workshops. Designed for employers and managers, the workshop covers a number of topics, including workers' compensation insurance, workplace safety, and overtime.



Publication
F101-101-000
 
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
 
Need a Doctor?
Information card: Provides contact information for injured workers needing assistance in finding a health-care provider who will treat their occupational injury or disease. This PDF will print out an 8.5" X 11" sheet that has 12 copies of the card. Note: Disclaimer information on Page 2 may not line up accurately in two-sided printing.

Publication
F160-006-000

Alt Language(s):
Español
 
Need a Doctor? - Spanish (¿Necesita un doctor?)
Information card: Provides contact information for injured workers needing assistance in finding a health-care provider who will treat their occupational injury or disease. This PDF will print out an 8.5" X 11" sheet that has 12 copies of the card. Note: Disclaimer information on Page 2 may not line up accurately in two-sided printing.

Publication
F160-006-999

Alt Language(s):
Inglés
 
On-the-Job Training
Postcard: For employers; summarizes the benefits of providing on-the-job training to an injured worker. The other side is for injured workers who want to return to work; explains how on-the-job training can help them. Includes website address and contact information.

Publication
F200-021-000
 
Self-Insurer Accident Report (SIF-2)

Provided to workers by the self-insured businesses or their third party claims administrators to report an industrial injury or occupational disease. This form is not on the internet. If you are an injured worker, ask your employer for a copy of this form. Self-insured businesses or their third party claims administrators may order copies of this form. Cllick the "order It" button below to order paper copies or request the form in MSWord.



Form
F207-002-000
 
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
 
Provider's Initial Report (PIR)

Used by medical providers when reporting initial treatment for an industrial injury or occupational disease for a self-insured claim. The paper version dated 10-2012 is still valid, as is the 01-2014 word fillable version.

Medical providers treating self-insured workers, self-insured businesses, or their third party claims administrators can access this form one of two ways:

  1. Download the Microsoft (MS) Word form and the PDF file with instructions:

           The first file is the PDF instructions.

           The second file is an Office 2003 MSWord document ending in .doc.

           The third file is an Office 2007/2010 version, ending in .docx.

2.  Order paper copies of this form by clicking the “order it” button.



Form
F207-028-000
 
Notice to Employees -- Self-Insurance/Aviso a los Empleados -- Seguro Industrial Propio (English/Spanish)

Required poster for self-insured businesses: Outlines what a worker employed by a self-insured business should do if a work-related injury or illness occurs. Note: Self-insured employers must display this poster where workers can see it.



Poster
F207-037-909
 
Self-Insured Employers' Time Loss Claim Closure Order and Notice

Used by only 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
F207-070-000

Alt Language(s):
Español
 
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
 
Employers' Guide to Self-Insurance in Washington State
Book: Explains the process for employers to provide their own industrial insurance (workers’ compensation) coverage in Washington State. Also reviews surety requirements for self-insurance, reporting and recordkeeping requirements, claims processing, and compliance and legal issues.

Publication
F207-079-000
 
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
 
SIF-5A Cover Sheet: Wage Calculations

Used by only self-insured employers and their representatives to calculate and report injured workers’ wages and time loss compensation rates.



Form
F207-156-000
 
SIF-4 Self Insured Employer's Request for Denial of Claim
Used by self-insured employers or their representatives to notify an injured worker that the employer or representative is requesting that L&I deny their claim.

Form
F207-163-000
 
Self-Insured Employers' Permanent Partial Disability Closure Order and Notice - 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
F207-164-000

Alt Language(s):
Español
 
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
 
Self-Insured Employers' Permanent Partial Disability Closure Order and Notice - 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
F207-165-000

Alt Language(s):
Español
 
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
 
Self-Insurance Certification Questionnaire

Used by employers applying to become self-insured to describe their proposed workers' compensation program.



Form
F207-176-000
 
Self-Insurance Vocational Reporting Form

Used by self-insured employers and their representatives to report to L&I an injured worker's eligibility for vocational services or ability to work. This replaces F207-121-000 Employability Assessment Report (EAR).



Form
F207-190-000
 
Your Independent Medical Exam: For Employees of Self-Insured Businesses
Pamphlet: Answers the most common questions about when and why an injured worker may be required to attend an independent medical exam. Includes the "IME Travel & Wage Reimbursement Request" form. This publication is for use only by self-insured businesses and their workers.

Publication
F207-202-000

Alt Language(s):
Español
 
Your Independent Medical Exam: For Employees of Self-Insured Businesses - Spanish (Su Examen Médico Independiente: Para empleadores de negocios autoasegurados)
Pamphlet: Answers the most common questions about when and why an injured worker may be required to attend an independent medical exam. Includes the "IME Travel & Wage Reimbursement Request" form. This publication is for use only by self-insured businesses and their workers.

Publication
F207-202-999

Alt Language(s):
Inglés
 
Coverage Agreement

An agreement between a worker and employer which states the worker's employment is principally localized in Washington state or another state.



Form
F212-044-000
 
Sports Teams Coverage Agreement

Used by a sports team or league covering their Washington players through an out-of-state workers' compensation insurance carrier to confirm compliance with RCW 51.12.120 and WAC 296-17-32503.



Form
F212-196-000
 
Sports Player Coverage Agreement

Used by a sports team or league and professional athlete (player) to declare that the player's work is principally localized in another state in accordance to the provisions of RCW 51.12.120 and WAC 296-17-32503.



Form
F212-242-000
 
Five Steps to File
Flyer: Reviews the steps for filing workers' compensation quarterly reports online and lists the filing due dates.

Publication
F212-243-000
 
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
 
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
 
Construction Industry Classification Guide

Book (loose-leaf manual): Helps contractors properly classify for workers' compensation insurance purposes the work being performed by their employees on new wood-frame building construction projects.



Publication
F213-008-000
 
Contract: Report By Landowner - Forest, Range & Timber Industry

The landowner needs to complete and submit this form before any contractural agreement with a forest, range and/or timber industry contractor can start any work that is covered by this agreement.



Form
F213-010-000
 
Contract: Report By Contractor - Forest, Range & Timber Industry

This report by the contractor needs to be completed and sent before any contractural agreement with a forest, range and/or timber industry landowner can start any work covered by this agreement.



Form
F213-011-000
 
Reforestation Contract Supplemental Report - Forest, Range and Timber Industry

Used by an employer to report worker hours for each individual contract with a timber landowner. This is a supplemental document to the Contract: Report by Contractor - Forest, Range & Timber Industry (F213-011-000).



Form
F213-013-000
 
Reforestation Industry Continuation Sheet (Over $10,000)

Used by contractors to report contracts over $10,000. Reforestation industry contractors must report worker hours for each individual contract with a timber landowner. This form should accompany the quarterly report.



Form
F213-015-000
 
The ABCs of Classifications in Washington
Book: Aids in understanding Washington State's workers' compensation classification system and how classifications are applied to different types of businesses.

Publication
F213-022-000
 
Application for Elective Coverage - Sole Proprietor, Partners, For-Profit Corporate Officers, or Member/Managers of Limited Liability Company (LLC)

Used by employers to apply for workers' compensation coverage for non-mandatory employment. Shows a list of categories of employment that are not considered mandatory to have workers' compensation.



Form
F213-042-000
 
Application for Elective Coverage of Excluded Employments

Used by employers to request coverage of workers' compensation for non-mandatory employment. Shows a list of employment categories to choose from that are not included within the mandatory coverage of workers' compensation.



Form
F213-112-000
 
Corporate Officers

Quick reference card: Explains the criteria to allow a corporate officer to be exempt from industrial insurance (workers' compensation) coverage. This information is part of the publication, Workers’ Compensation Record Keeping and Report Guides.



Publication
F214-010-000
 
Record Keeping

Quick reference card: Identifies the type of records employers, including construction contractors, need to keep to allow L&I to compute premiums. This information is part of the publication, Workers’ Compensation Record Keeping and Report Guides.



Publication
F214-011-000
 
Independent Contractors

Quick reference card: Provides information to help determine whether a "subcontractor" working for you meets the legal requirements to be an independent contractor, or whether he/she is actually a covered worker for workers' compensation (industrial insurance) purposes. This information is part of the publication, Workers’ Compensation Record Keeping and Report Guides.



Publication
F214-012-000
 
Excluded and Exempt Employments

Quick reference card: Provides a list of employments excluded from workers' compensation coverage, including those eligible for optional coverage. This information is part of the publication, Workers’ Compensation Record Keeping and Report Guides.



Publication
F214-013-000
 
Standard Exception Classification

Quick reference card: Provides basic information about standard exception classifications, which can be separately rated from the basic business classification for determining industrial insurance (workers' compensation) premiums. This information is part of the publication, Workers’ Compensation Record Keeping and Report Guides.



Publication
F214-016-000
 
Audit Reference Card
Quick reference card: Answers questions employers may have about audits L&I conducts to verify the that workers' hours have been reported correctly and workers' compensation premiums have been calculated accurately.

Publication
F214-020-000
 
Limited Liability Companies (LLC)

Quick reference card: Reviews the requirements for members or managers of limited liability companies to be exempt from workers' compensation (industrial insurance) coverage. This information is part of the publication, Workers’ Compensation Record Keeping and Report Guides.



Publication
F214-021-000
 
Request for Manuals from Claims Training

Fillable form to purchase the Workers’ Compensation Adjudicator (WCA), Claims Management (CM), and Policy Manuals (all 3 manuals on 1 CD) the costs will be added up automatically, the total amount enclosed column will be the amount you need to send as payment.



Form
F241-021-000
 
Claim for Pension by Spouse or Children
Used by a spouse or dependents of a deceased worker. The workers' fatal accident or occupational disease incurred in the course of their employment. This application is needed to determine if applicant(s) is/are entitled to a survivor benefit.

Form
F242-056-000

Alt Language(s):
Español
 
Claim for Pension by Spouse or Children -  Reclamo para Beneficios de Pensión Presentado por el Cónyuge, Pareja Doméstica Registrada o los Hijos (Spanish)

Used by a spouse or dependents of a deceased worker. The workers' fatal accident or occupational disease incurred in the course of their employment. This application is needed to determine if applicant(s) is/are entitled to a survivor benefit.



Form
F242-056-999

Alt Language(s):
Inglés
 
Claim for Pension By Dependents
Used by dependents of a deceased worker to file a claim for benefits.

Form
F242-062-000

Alt Language(s):
Español
 
Reclamo para Beneficios de Pensión Presentado por los Dependientes

Used by dependents of a deceased worker to file a claim for benefits.



Form
F242-062-999

Alt Language(s):
Inglés
 
Occupational Disease & Employment History

Injured worker fills this out to document possible occupational disease and to show work history.



Form
F242-071-000

Alt Language(s):
Español
 
Application to Reopen Claim Due to Worsening Condition

This application is by injured workers and providers to apply to reopen an industrial injury or occupational disease claim due to worsening condition for claims that have been claims 60 days or longer.



Form
F242-079-000

Alt Language(s):
English/Español
Español
 
Application to Reopen Claim due to Worsening Condition - Spanish APLICACIÓN PARA REABRIR UN RECLAMO

Used by injured workers and doctors to apply to reopen an industrial injury or occupational disease claim that has been closed for longer than 60 days.



Form
F242-079-909

Alt Language(s):
Inglés
Español
 
Application to Reopen Claim due to Worsening Condition - Spanish Aplicación para Reabrir un Reclamo Debido al Empeoramiento de la Condición 

Spanish version. Used by injured workers and doctors to apply to reopen an industrial injury or occupational disease claim that has been closed for longer than 60 days.



Form
F242-079-999

Alt Language(s):
Inglés
English/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
 
Employment History Form Spanish Formulario de Historial de Empleo

Used by injured worker to report their employment history for the past three years and the wages at each job.



Form
F242-109-999

Alt Language(s):
Inglés
 
Report of Accident Instructions -- Spanish Instrucciones para el Reporte de Accidente

This document provides instructions in Spanish on how to complete the worker portion only of the Report of Accident (ROA). Please note that the Report of Accident is not available in Spanish. To order these instructions from the L&I Warehouse, please use the link below.

http://www.Lni.wa.gov/ClaimsIns/Providers/FormPub/ROA/OrderROA.asp



Form
F242-130-999

Alt Language(s):
Inglés
 
Declaration of Entitlement for Widow or Widower Benefits Under Industrial Insurance
Used by the widow/widower whose spouse died of a work related injury or accident. This form must be completed, signed, notarized and returned to L&I within 30 days for non interruption of your benefits.

Form
F242-173-111

Alt Language(s):
Español
 
Declaration of Entitlement for Guardian Benefits under Industrial Insurance
Used by a guardian or other person having custody of the minor or disabled children or dependents of a deceased worker to declare their entitlement to receive the pension benefits for those children/dependents in their care and custody.

Form
F242-173-222

Alt Language(s):
Español
 
Declaración de Derechos para Viuda(o) bajo el Programa de Compensación y Beneficios para Trabajadores

Used by the widow/widower whose spouse died of a work related injury or accident. This form must be completed, signed, notarized and returned to L&I within 30 days for non interruption of your benefits.



Form
F242-173-911

Alt Language(s):
Inglés
 
Declaración de Derechos para Padres o Tutor Bajo el Programa de Compensación y Beneficios para Trabajadores

Used by a guardian or other person having custody of the minor or disabled children or dependents of a deceased worker to declare their entitlement to receive the pension benefits for those children/dependents in their care and custody.



Form
F242-173-922

Alt Language(s):
Inglés
 
Declaración de Derechos para Dependiente del Trabajador Fallecido Bajo el Programa de Compensación y Beneficios para Trabajadores

Used by a dependent of a worker whose death was related to an on the job injury or accident. This form must be completed, signed, notarized and returned to L&I within 30 days for non interruption of benefits.



Form
F242-173-933

Alt Language(s):
Inglés
 
Declaración de Derechos para los Beneficios de un Trabajador Totalmente Discapacitado Bajo las Leyes del Seguro Industrial

Used by a totally permanently disabled worker. This form must be completed, signed, notarized and returned to L&I within 30 days for non interruption of benefits.



Form
F242-173-944

Alt Language(s):
Inglés
 
Notice to Employees -- If a Job Injury Occurs/Aviso a los empleados--Si Ocurre una Lesión en el Trabajo (English/Spanish)

Required poster: Outlines the steps a worker should take if a job-related injury or illness occurs. Also briefly describes the benefits available through Washington's workers' compensation system. Note: 'Employers who receive industrial insurance coverage from L&I must display this poster where workers can see it. English and Spanish online versions will print separately.



Publication
F242-191-909
 
Notice of Occupational Disease or Infection

Used by medical providers to notify L&I that an occupational disease or infection has been diagnosed and that the worker has been advised that their condition may be work-related. This form can be used if the worker does not complete a Report of Accident or Occupational Disease (ROA) but should not be completed in place of an ROA.



Form
F242-243-000
 
How to Protest a Department of Labor and Industries Decision (English/Spanish) Cómo Protestar una Decisión en su Reclamo del Departamento de Labor e Industrias

Fact sheet: Explains how an injured worker can protest decisions on his/her claim and gives deadlines for taking action.



Publication
F242-363-909
 
Insurer Activity Prescription Form

Used by health-care providers to communicate an injured worker's status, physical capacities, inability to work (time-loss) and treatment plans. To print an APF, click on the title of the form in the box above.



Form
F242-385-000

Alt Language(s):
English/Español
 
Insurer Activity Prescription Form - Spanish Formulario de Restricciones Laborales del Asegurador

Used by Spanish speaking health-care providers to communicate an injured worker's status, physical capacities, inability to work (time-loss) and treatment plans.

Utilizado por proveedores de cuidado de la salud que hablan español para indicar la condición actual del trabajador lesionado, restricciones físicas, certificación de tiempo perdido y planes de tratamiento.



Form
F242-385-909

Alt Language(s):
Inglés
 
Application for Pension Benefits by Spouse or Children

Used by a spouse or dependent that was chosen by the deceased worker to receive a survivor benefit. At the time the worker was determined to be totally permanently disabled he/she made a decision to leave a survivor benefit to a spouse or dependent if the worker dies.



Form
F242-391-000

Alt Language(s):
Español
 
Application for Pension Benefits by Spouse or Children - (Spanish) Aplicación para Beneficios de Pensión Presentado por el Cónyuge o Hijos

Used by a spouse or dependent that was chosen by the deceased worker to receive a survivor benefit. At the time the worker was determined to be totally permanently disabled he/she made a decision to leave a survivor benefit to a spouse or dependent if the worker dies.



Form
F242-391-999

Alt Language(s):
Inglés
 
Pension Benefits Questionnaire

Used by an injured worker who receives an order that states he or she is totally permanently disabled. This questionnaire must be completed in full and all necessary documents attached before his or her pension benefit options can be calculated.



Form
F242-393-000

Alt Language(s):
Español
 
Pension Benefits Questionnaire - Spanish Cuestionario para Beneficios de Pensión

Used by an injured worker who receives an order that states he or she is totally permanently disabled. This questionnaire must be completed in full and all necessary documents attached before his or her pension benefit options can be calculated.



Form
F242-393-999

Alt Language(s):
Inglés
 
Affidavit for Time Loss Compensation Benefits

Completed by injured workers contending eligibility for payment of back time loss benefits for a period that exceeds six months or $25,000. Injured workers requesting benefits for current time missed from work due to a work-related injury should use the F242-052-000 Worker Verification Form.



Form
F242-395-000

Alt Language(s):
Español
 
Affidavit_for_Time_Loss_Compensation_Benefits (Spanish) Declaración Firmada para Compensación de Tiempo Perdido

Affidavit_for_Time_Loss_Compensation_Benefits (Spanish) Declaración Firmada para Compensación de Tiempo Perdido Completed by injured workers contending eligibility for payment of back time loss benefits for a period that exceeds six months or $25,000. Injured workers requesting benefits for current time missed from work due to a work-related injury should use the F242-052-999 Worker Verification Form.



Form
F242-395-999

Alt Language(s):
Inglés
 
Have you been injured on the job?-Spanish (Se ha Lesionado en el Trabajo?)

Wallet card: Explains how to file a workers' compensation claim by telephone.



Publication
F242-404-999
 
Transfer of Care Card

Used by injured worker to notify claim manager and request authorization to transfer care to a different doctor. Do it online! Use the online Transfer of Care



Form
F245-037-000

Alt Language(s):
Español
 
Transfer of Care Card (Spanish) Tarjeta para Transferencia de Caso

Used by injured worker to notify claim manager and request authorization to transfer care to a different doctor.



Form
F245-037-999

Alt Language(s):
Inglés
 
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
 
Interpretive Services Appointment Record

This form is used when an interpreter is appointed to interpret for an injured worker during their medical visits.

When ordering, there is a limit of 4 pads, or 100 copies total. Fax your request to the L&I Warehouse at 360-902-4525 or email whsemail@Lni.wa.gov   Include the following in your request: Your name, mailing address, and telephone number and form number F245-056-000.



Form
F245-056-000
 
Frequently Asked Questions about Job Modifications
Fact sheet: Answers questions employers, workers and doctors may have about job modifications, including when to request a job-modification consultant and who pays for the costs involved.

Publication
F245-057-000
 
Physical Therapy / Occupational Therapy Progress Report to Claim Managers

The physical / occupational therapist uses this report to identify the clinical goals and return to work objectives of the injured worker.



Form
F245-059-000
 
Statement for Miscellaneous Services

This bill form is used by providers and injured workers to bill the department for services such as dental care; glasses; medical equipment; nursing home services; interpreter services; services workers pay for out of pocket; and other services. Information on how to bill the department can be found in the General Provider Billing Manual [F248-100-000].

 



Form
F245-072-000

Alt Language(s):
Español
 
Statement for Pharmacy Services

Bill form for prescription charges. May be used by a pharmacy to submit drug charges, or by a worker to request reimbursement for prescriptions paid out of pocket. See the General Provider Billing Manual (F248-100-000) for information on completing this form.



Form
F245-100-000
 
CMS 1500 (formerly L&I Health Insurance Claim form)
Used by providers to be reimbursed for services. It is NOT for use by injured workers to submit a claim to L&I.

Form
F245-127-000
 
Travel Reimbursement Request

Bill form for use by workers to request reimbursement for authorized travel expenses.



Form
F245-145-000

Alt Language(s):
Español
 
Travel Reimbursement Request - (Spanish) Solicitud para el Reembolso de Gastos de Viaje

Injured workers use this form to request reimbursement for travel expenses used to receive treatment, retraining and/or vocational services.



Form
F245-145-999

Alt Language(s):
Inglés
 
Your Independent Medical Exam

Pamphlet/booklet: Answers the most common questions about independent medical exams and when and why an injured worker may be required to receive one. Includes the "IME Travel & Wage Reimbursement Request" form.



Form
F245-224-000

Alt Language(s):
Español
 
Job Modification Assistance Application

For use by an vocational counselor, employer, etc. to request modification for the injured workers job. This may involve tools and equipment that is purchased through L&I.



Form
F245-346-000
 
Pre-Job Accommodation Assistance Application

For use by a therapist or vocational provider to request job modification for an injured worker before the injured workers is employed, possibly in a retraining program. This may involve tools and equipment that is purchased through L&I.



Form
F245-350-000
 
Vocational Training Plan Ownership Agreement for Tools and Equipment

Injured worker agrees to the ownership terms of the tools and/or equipment purchased as part of their training plan by L&I.



Form
F245-351-000
 
Plan Time Encumbrance
To record the work plan time. For use only with plans approved after 1/1/2008.

Form
F245-376-000
 
Long Term Care Assessment Tool

You must mail or fax form. No emailed forms are accepted. This assessment tool is provided by L&I assessment to determine the medically appropriate level of care that will meet the Injured Worker’s needs, abilities and safety in a residential facility. This assessment is not intended as a substitute for DSHS annual assessment & treatment plan, which is the sole financial responsibility of the facility.



Form
F245-377-000
 
Hearing Aid Repair Authorization Fax Request

Hearing Aid Repair Authorization Requests. If you need to purchase or replace a hearing aid, fax all of the information required by Medical Aid Rules and Fee Schedule (MARFS) including the Hearing Services Worker Information (F245-049-000) to 360-902-6252.



Form
F245-384-000
 
Department of Labor and Industries Home Modification Acknowledgement of Responsibilities

Used by both workers and bidding contractors to read, sign and submit to L&I to verify that they have read, understand and accept their respective responsibilities in the home modification process.



Form
F247-003-000
 
Electronic Billing Authorization

To authorize L&I to accept electronically submitted bills for services provided to injured workers (2 pages).



Form
F248-031-000
 
Injured by a third party?  

Brochure: Summarizes the legal rights and options an injured worker has if a third-party action pertains to his/her workers' compensation claim. Includes the Third Party Election Form that must be completed by the worker. Note: The form must be printed, signed and mailed.



Form
F249-008-000

Alt Language(s):
Español
 
Application for Inclusion on List of Eligible Attorneys
Used by attorneys to be included on the Workers' Compensation Special Assistant Attorney General Program eligible list for Third Party claims.

Form
F249-017-000
 
Is Retrospective Rating Right for You?
Pamphlet: Provides information about L&I's Retrospective Rating Program. In Retro, employers can earn a partial refund of workers' compensation premiums if they reduce workplace injuries and lower associated claim costs.

Publication
F250-006-000
 
Application for Limited Elective Coverage for Licensed Pony Riders

This form is used to provide free-agents the ability to obtain workers’ compensation insurance benefits.



Form
F250-026-000
 





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