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.

This affidavit is used to record the hours of a trainee's electrical experience with direct supervision under a Washington certified journeyman, master or specialty electrician.

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.

Checklist for homeowners on how to upgrade their pre-HUD homes to approach the HUD standards in the area of fire safety.

This is the form you would complete to register as a construction conractor.

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.

Application and instructions for a Washington State electrician's certificate examination.

Benefits are limited to $50,000 per claim. if your claim has met or exceeded this cap, your reopening application will be denied and we will be unable to pay any further benefits. Used by victims of crime and medical or mental health providers to request a claim be reopened.

Benefits are limited to $50,000 per claim. if your claim has met or exceeded this cap, your reopening application will be denied and we will be unable to pay any further benefits. Used by victims of crime and medical or mental health providers to request a claim be reopened.

Contractors may use this form to request an Assignment of Account in lieu of a surety bond. The amount of the surety bond would need to be placed into an account at a WA State Bank.

There are instructions in one PDF file, and a blank form that may be printed in the other PDF. The word document is saved in Microsoft 2003 format and is a fillable word form.

Class B Book Refund Request Form for the purpose of requesting a refund of Class B Books purchased prior to March 1, 2013.

This form may be faxed to the Contractor Registration office in Tumwater.

Used to get approval of a course as an electrical continuing education class. This application must be received by L&I at least 30 days before the course is offered.

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.

Used by a licensed massage practitioner/clinic to request authorization for outpatient massage therapy services for L&I claims.

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

Used by a therapy provider/clinic to request authorization for outpatient occupational or physical therapy services for L&I claims.

This form is a coversheet used by Self-Insurance for overpayment reimbursement fund requests.

For legal guardians and school officials to approve the hours and work activities for a minor employee to work according to terms listed by the employer. The Special Variance allows additional hours of work for 16- and 17-year-olds and is described on the form. All parties must sign to approve the hours of work for a minor regardless of the number of hours listed. This is NOT a work permit. Employers must obtain a minor work permit endorsement on their Master Business License where they employ workers under 18.

This is a copy of the law that pretains to the payment of wages to an employee when they stop working for an employer. The wages due to the employee for the pay period worked prior to leaving.

A form to request a refund for an electrical work permit, elevator permit, or factory-assembled structure alteration permit.

Used in requesting a plan approval for Conversion Vendor or Medical Unit factory-assembled structures.

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.

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.

In order to do independent medical exams a provider must obtain a provider account number with L&I. This packet includes the application and agreement with instructions, IME Provider Exam sites form (F245-047-000) and Request for Taxpayer ID and Certification - Form W-9 (F248-036-000) (10 pages). If you have questions, please email balk235@lni.wa.gov or call 360-902-6815.

Used by medical providers when reporting initial treatment for an industrial injury or occupational disease for a self-insured claim. Medical providers treating self-insured workers, self-insured businesses, or their third party claims administrators may order copies of this form. Click the "order it" button to request paper copies. If you download the MS Word form, also download the PDF file with instructions on use of the MS Word form. The first file is an Office 2003 MSWord document with a .doc extension. The second file is an Office 2007/2010 version, with a .docx extension.

Providers use this to report total overpayment, partial overpayment and/or underpayment by L&I. These forms will be accepted by L&I. They may not be accepted by all Medical Bill Processors due to lack of a barcode.

Fact sheet: Explains how an employer requests a "stay of abatement date." Effective July 1, 2012, an employer must fix a hazard cited in a workplace inspection during appeal unless he or she has requested and been granted a stay of abatement date.

You can submit a Report of Accident (ROA) online https://secure.lni.wa.gov/home This form is not on the internet. If you are an injured worker, ask your doctor for a copy of this form. Order F242-130-999 from the warehouse to receive the instructions in Spanish to complete the form in English.

To request a duplicate or replacement of your Washington state electrical license or certificate.

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.

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

To request public records from Washington State Dept. of Labor and Industries. You can order an earlier version from the LNI warehouse until stock is exhausted.

Used by employers to present L&I with a list of decisions they are protesting by adjustment period. The form requests all necessary elements needed for L&I to process a request for reconsideration.

The purpose of the manufactured home roof affidavit is to provide timely inspections and communications between the contractor and/or owner and FAS inspectors and field staff.

A structural inspection request questionnaire will not be required when a roof change out occurs if no structural changes are made in the roof sub-surface and roof cavity. Example: Repairing or replacing the roof trusses, rafters, ridge beam and the replacement of not more than (4) 4’x 8’ of roof sheathing.

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.

This is a data change request form. F207-193-000 is the Self-Insurance Electronic Data Reporting System (SIEDRS) Enrollment Form

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.

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

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

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

Used to obtain a vocational provider account number with L&I. This form includes a copy of F248-036-000 "Request for Taxpayer ID number and Certification". (12 pages) CURRENT EXISTING VOCATIONAL PROVIDER FIRMS THAT ARE ALREADY REGISTERED WITH L&I USE THIS FORM AND W-9.

This is a waiver of lien by a contractor or a subcontractor or supplier.

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

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.

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.

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.

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.

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.

F700-164-000 is an addendum to your Affidavit of Wages Paid Form. RCW 39.04.370 requires you to complete form F700-164-000 if the prime contract is at a cost of over one million dollars ($1,000,000). If you fail to properly provide the requested information more than one time between September 1, 2010 and December 31, 2013, pursuant to RCW 39.04.350(1)(f) you will not be considered a responsible bidder qualified to be awarded a public works project. Use as many of these forms as you need in order to provide the requested information for all relevant project items. This is an addendum to form F700-007-000.

This form is to request L&I to release public records in the contractors registration section.

Used by non-L&I agencies and jurisdictional authorities to request an inspection on an electrical hazard.

EXAMPLE ONLY: Example of an application to apply for an apprenticeship. Registered Apprenticeship Programs use their own forms. NOT TO BE USED TO REQUEST PLUMBER or ELECTRICAL TRAINEE CARD.

Application used to get an electrical contractors license

Application form: Small farm owners wishing to participate in the pilot small farm internship program must complete this form and submit it to the department. The information requested on the form is required to process an application for approval in order to issue a certificate of participation.

The purpose of form 212-234-000 -Out of state applications- is to provide a means for an employer to formally request to receive the out-of-state supplemental report for a specific year and state. The form will also allow the department to convey out-of-state reporting requirements and to obtain information needed by the department to set a business up for supplemental reporting.

To request access to L&I's EPIS - Miscellaneous Accounts

Contractors may use this form to request an Assignment of Account in lieu of an insurance policy for bodily injury. The amount of the insurance policy would need to be placed into an account at a WA State Bank.

Contractors may use this form to request an Assignment of Account in lieu of an insurance policy for property damage. The amount of the insurance policy would need to be placed into an account at a WA State Bank.

Board of Boiler Rules Extension of Inspection Frequency Request Form

Used to submit written requests for interpretations and revisions to the definitions, rules and regulations found in WAC 296-104. These must be submitted 45 days prior to the Board of Boiler Rules Meeting date. To use this form, left click on the link and select SAVE TARGET AS and save to your desktop. Open in WORD, complete form, select PRINT, SEND TO, MAIL or DELIVERY DOCUMENT ONLY in care of Chief, Boiler Inspector.

Board of Boiler Rules Washington State Specials Request Form

To request a clearance variance on a boiler or pressure vessel. You can only mail or fax this form to L&I. E-mailed forms are not accepted.

Chief Inspector Clarification and Interpretation Request Form

Employers use this form to request reimbursement for the reasonable costs of training, travel, recordkeeping, and medical expenses for Cholinesterase Monitoring.

This form is to be used by suppliers to notify homeowners that they have the ability to file a construction lien against their property if payment is not received.

Used by the contractor to request L&I to release assignment of account that they used instead of a surety bond.

Crime Victims Address Change Request

Used by the clinical provider to request authorization to provide more than six sessions. This form must be submitted by the sixth session. (6 pages)

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

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

Used by injured worker who has filed an occupational hearing loss claim to provide more specific information regarding how the hearing loss occurred. This is requested by the Claim Manager and sent to the Injured Worker.

Used by the manufacturer to request approval from L&I on an eletrical plan to build factory-built structures or commercial coaches.

Fact Sheet: Provides information for requesting electrical inspections, including telephone numbers and locations of L&I offices that handle electrical inspections.

Electrical Telecommunication Principal Member Owner Update Request

This form is to request a time extension from an unforeseen circumstances for overdue corrections for conveyances.

Used by a homeowner or contactor to request a field inspection for an alteration to a manufactured or mobile home.

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.

This variance request applies only to the installations performed by a previous owner and does not apply to any home during the warranty period.

IME Doctor’s Estimate of Physical Capacities: For use by independent examiners when asked to estimate physical capacities as part of an IME requested by the department.

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.

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.

Labor and Industries Prosthetic Device Request Form

Manufactured Home Installer Certification Tag Transfer Request form

This form is so L&I's Office of the Medical Director can evaluate medical device(s) that the attending physican wants to use to treat an injured worker.

Used to order L&I medical forms.

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. The first EXCEL document is in Office 2007 format. The second file, with the same title, is in Office 2003 format.

Used by injured worker who has filed an occupational hearing loss claim to provide more specific information regarding how the hearing loss occurred. This is requested by the Claim Manager and sent to the Injured Worker.

VRCs can use this form to request information on a specific on -the -job (OJT) training opportunity listed on L&I's website, or to recommend an OJT training opportunity.

Used by the owner for red tagging a unit that is to be placed or to remain out of service.

A manufacturer of factory-built structures and/or commercial coaches uses this form to submit plans to L&I for review.

Plans to build recreational vehicles or park trailers need approval from L&I. This form is used as part of the approval process.

Plumber Request for Change of Address

Checklist which reflects the most common violations encountered by Field Inspectors. This checklist should be gone through prior to requesting inspection of Hot Water Heating or Hot Water Supply Boilers

Ask L&I to conduct an investigation into a prevailing wage violation that affects one or more employees. See box 30 on the form to see what types of complaints are covered.

Ask L&I to conduct an investigation into a prevailing wage-related issue that affects one or more employees.

Providers use to inform L&I that they have changes to their account. Such as changes to their Tax ID address/name, business address, billing address, name, or termination of account. This also includes a W-9 form.

The provider network agreement for participation in the health care provider network for injured workers covered by Washington State Fund and self-insured employers.

Used by providers to request an adjustment to their bill if their entire bill was paid in error, or if a portion of the bill was overpaid or underpaid. Attach required reports and/or documentation to support the request.

Contractors may use this form to request changes to a Assignment of Savings that was filed in lieu of a surety bond or insurance policy.

To request a permit to use a rental boiler at one location only.

Used to request a duplicate elevator license or a duplicate operating permit for a conveyance.

Request for new apprenticeship standards.

This form is to request L&I to release archive records in the contractors registration section.

Used to request copies of Certified Payrolls for prevailing wage projects.

To request a cancellation of a new apprenticeship committee which never has a "Request for New Standards" approved by the WSATC

Used for cancelling an apprenticeship program.

Used by electrical licensee to notify L&I of an address change.

Used to request a change of status for apprentices, the training agreements or the training agents. These are normally accompanied by Committee meeting minutes when submitted.

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

Request for Duplicate Elevator Mechanic License

This form is used to request a duplicate or replacement certificate for a plumber or plumber trainee.

Used to establish a new apprenticeship committee and list it's employer/employee representatives.

Used to request revision of committees to include changing the title of the standards, sub-committees, and training directors/coordinators.

Used to request a revision of standards except for committee members.

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

Used by sponsors or instructors of continuing education courses, when requesting the department assign credit to a course so that department-approved claims administrators who attend can earn credit toward recertification under the Self Insurance Continuing Education program.

Used by self-insured employers and third party administrators to enroll for participation in the Self Insurance Electronic Data Reporting System (SIEDRS). F207-197-000 is SIEDRS (Self-Insurance Electronic Data Reporting System) Data Change Request.

Used by only self-insured employers or their representatives to report initial time loss payments or to request interlocutory, wage, overpayment or closure orders.

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.

Used by self-insured employers to request reimbursement from L&I for cost-of-living-adjustments paid to injured workers.

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.

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.

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.

Structural Inspection Request Questionnaire

This form is to be used to purchase the CD ROM of registered construction contractors, registered electrical contractors, plumbers and electricians.

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

If you are considered a victim of crime, use this form to track your travel expenses for medical, retraining or vocational services or for an independent medical exam. You should have approval from your claim manager before you travel.

Employer application request for a variance from employment standards for non minor employees.

Employer uses this application for requesting a variance to employment regulations for minors.

For use by crime victims requesting time-loss compensation

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.

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.

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.

Fact Sheet: Provides answers to commonly asked questions about independent medical exams (IMEs) and contact information. Includes a form for requesting travel-related reimbursement for attending an IME.

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.

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.