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Schedule of Future Payments for the Balance of the Permanent Partial Disability Award

Schedule of Future Payments for the Balance of the Permanent Partial Disability Award.



Form
F207-162-000
 
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
 
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
 
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
 
Assignment of Account Agreement
Used by a self-insured employer as an option to provide collateral for a total permanent disability claim.

Form
F207-058-000
 
Self-Insurer's Pension Bond

Used by self-insured employers as an option to provide collateral for a permanent total disability claim.



Form
F207-065-000
 
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
 
Pension Bond Rider
Used by a self-insured employer to change items on the surety document such as amount of pension bond issued to secure a total permanent disability claim.

Form
F207-120-000
 
Memorandum of Understanding

Used by a self-insured employer to signify the employer's obligation and responsibilities in conjunction with providing an annuity as collateral for a total permanent disability claim.



Form
F207-129-000
 
Notificación de Decisión de Cierre con Discapacidad Parcial Permanente para Empleadores Autoasegurados - PPD-TL

Used by self-insured employers or their representatives only, this is legal notification to an injured worker that their claim is being closed. This order is used only when time loss compensation has been paid, and a permanent partial disability award is also being paid.



Form
F207-164-999

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

Used by self-insured employers or their representatives only, this is legal notification to an injured worker that their claim is being closed. This order is used only when time loss compensation has not been paid, but a permanent partial disability award is being paid.



Form
F207-165-999

Alt Language(s):
Inglés
 
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
 
Safety and Health Investment Projects (SHIP) Grant Program

Booklet: Introduces the SHIP Grant Program and application process. SHIP awards grants for innovative projects that (1) prevent workplace injuries, illnesses and deaths and (2) encourage injured workers to return to work early and reduce long-term disability.



Publication
F417-224-000
 
Verification of School Enrollment

Used by the student and a school official each quarter to verify school enrollment.



Form
F242-055-000

Alt Language(s):
Español
 
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
 
Address Change Request for Pensioners

Used by the pensioner to notify L&I of a new mailing address. L&I must receive this form by the first day of the month so your monthly payment is received in a timely manner.



Form
F242-107-000

Alt Language(s):
Español
 
Address Change Request for Pensioners - (Spanish) Solicitud para Cambio de Direccion para Pensionados

Used by the pensioner to notify L&I of a new mailing address. L&I must receive this form by the first day of the month so your monthly payment is received in a timely manner.



Form
F242-107-999

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
 
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
 
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
 
Authorization for Deposit of Payments

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



Form
F242-174-000

Alt Language(s):
English/Español
 
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
 
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
 
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
 
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
 
Letter of Intent for School Enrollment
Use by a full-time student who is entitled to receive pension benefits. The student must be at least 18 years old and no older than 23 years old. This form is to prove the students intention to register in an accredited school during the next quarter/semester.

Form
F242-382-000

Alt Language(s):
Español
 
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
 
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
 





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