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Application for Construction Contractor Registration

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



Form
F625-001-000
 
Assignment of Account - WA State Banks Only

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.



Form
F625-008-000
 
Facts About Construction Liens
Fact sheet: Explains the basics of the construction lien law to help consumers protect themselves.

Publication
F625-017-000
 
Waiver of Lien by Contractor, Subcontractor(s) and Supplier

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



Form
F625-029-000
 
Model Disclosure Statement Notice to Customer

This disclosure statement is given to the consumer (customer) from the contractor showing they are registered in the state of Washington. The consumer (customer) signs this form as acknowledgement of receipt.



Form
F625-030-000
 
Contractor Complaint Form

Used by a home owner to file a complaint against a contractor.



Form
F625-033-000
 
Contratistas de Construcción: Obtenga los Datos, Regístrese

Pamphlet/booklet: Explains the steps to register as a construction contractor in Washington State.



Publication
F625-040-999

Alt Language(s):
Inglés
 
Subscription Request for Construction Contractor and Electrical Basic - CD

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



Form
F625-051-000
 
Filing Suit Against an Electrical Contractor

Instructions for filing suit against an electrical contractor



Form
F625-053-000
 
Construction Lien Notice

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.



Form
F625-054-000
 
Construction Lien Summary

General requirements that a lien claimant of a private construction project (not a commercial) must meet. This is intended show the general requirements for most lien claimants.



Form
F625-055-000
 
Contractor Financial Information

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



Form
F625-061-000
 
Affidavit to Release Public Records

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



Form
F625-066-000
 
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
 
Assignment of Account or Time Deposit for Insurance - Bodily Injury - WA State Banks Only

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.



Form
F625-082-000
 
Assignment of Account or Time Deposit for Insurance - Property Damage - WA State Banks Only

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.



Form
F625-083-000
 
What You Should Know About Hiring a Contractor, Remodeler, or Handyman

Pamphlet/booklet: Provides a checklist for consumers considering hiring a general or specialty construction contractor, reviews the permitting process, and suggests ways to avoid lien problems. Washington State law requires contractors to register with L&I.



Publication
F625-084-000

Alt Language(s):
Español
 
What You Should Know About Hiring a Contractor, Remodeler, or Handyman - Spanish (Lo que Usted Debe Saber paraContratar a un Contratista, Remodelador o Empleado de Mantenimiento (Handyman))  

Fact sheet: Provides a checklist for consumers considering hiring a general or specialty construction contractor, reviews the permitting process, and suggests ways to avoid lien problems. Washington State law requires construction contractors to register with L&I.



Publication
F625-084-999

Alt Language(s):
Inglés
 
What to Do if You Want to File Suit Against Your Construction Contractor

Fact sheet: Provides consumers with general information about the process for filing suit, and describes L&I's limited role in serving Summons & Complaint papers.



Publication
F625-088-000
 
Washington Contractor's License Bond Validation Rider

This rider is intended to be used in conjunction with a bond.



Form
F625-098-000
 
Washington Contractor's License Bond Name Change Rider

Used by the bond company to change the name of the contractor's business.



Form
F625-099-000
 
Washington Contractor's License Bond License Number Change Rider

Used by the bond company to change the contractor's business license number.



Form
F625-100-000
 
Washington Contractor's License Bond Date Change Rider

Used by the bond company to change the effective date of the contractor's bond.



Form
F625-101-000
 
Washington Contractor's License Bond Bond Amount Rider

Used by the bond company to amend the amount of the contractor's bond.



Form
F625-102-000
 
Washington Contractor's License Bond Entity Change Rider

Used by the bond company to show a change in the business structure of a contractor's business.



Form
F625-103-000
 
Washington Contractor's License Bond Address Change Rider

Used by the bond company to change the address of the contractor's business.



Form
F625-104-000
 
Renewal Application for Contractor Registration

Renewal Application for Contractor Registration



Form
F625-107-000
 
Contractor Registration Request for Duplicate License or Address Change  

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



Form
F625-108-000
 
Application for Agent On-Line Insurance Entry Account

Application for Agent On-Line Insurance Entry Account



Form
F625-110-000
 
Upgrade from Specialty Contractor to General Contractor

Used to apply for an upgrade from Specialty Contractor to a General (01) Contractor.



Form
F625-113-000
 
Application for Electrician Examination

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



Form
F626-001-000
 
Application / Renewal for an Electrical Training Certificate

This the application for an Electrical Training Certificate or the renewal of. (This does NOT make you a registered apprentice).



Form
F626-048-000
 
Application for Plumber Trainee Certificate

This form is used to apply for a plumber trainee certificate.



Form
F627-003-000
 
Affidavit of Experience - Plumbers

This form is required to report plumber trainee's plumbing experience for credit towards journey level or specialty status.



Form
F627-004-000
 
Application for Plumber Examination, Reciprocal, Medical Gas Endorsement, or Temporary Permit

This form is used to apply for plumber examination, reciprocal and medical gas endorsement.



Form
F627-008-000
 
Request for Duplicate or Replacement Certificate

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



Form
F627-014-000
 
Plumber, Medical Gas, or Trainee Renewal

This form is used to renew a plumber certification, plumber trainee or medical gas installer certification.



Form
F627-019-000
 
Facts about State Certification for Plumbers
Fact sheet: Explains plumber classifications, certification requirements, including required exams, and the application and renewal processes, including continuing education requirements.

Publication
F627-022-000
 
Facts about Medical Gas Piping Installer Endorsement
Fact sheet: Explains training requirements and the endorsement process for medical gas piping installers.

Publication
F627-026-000
 
Plumbers Examination Dates and Locations

The 2014 Plumber Examination Dates and Locations. A printed version is also available from the L&I Warehouse.



Form
F627-027-000
 
Application for Backflow Trainee Certificate

This form is used to apply for a backflow trainee certificate.



Form
F627-033-000
 
Application for Backflow Specialty Exam

This form is used to apply for the backflow specialty examination.



Form
F627-035-000
 
Plumber Continuing Education Course Application

This form is used by the course sponsor to submit continuing education courses for plumber certification.



Form
F627-037-000
 
Plumber Request for Change of Address
Plumber Request for Change of Address

Form
F627-039-000
 
Affidavit of Continuity Medical Gas Installation

Affidavit of Continuity



Form
F627-043-000
 
Hiring a Plumber? Hire Smart!

Worksheet: Provides advice and step-by-step hiring tips for homeowners planning a remodel, repair or addition to their home that involves plumbing. Tells homeowners how to verify that a construction contractor is registered and a plumber is certified with the state.



Publication
F627-044-000
 
Parent / School Authorization for Employment of a Minor and Special Variance

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.

For hiring youth only during non-school weeks, you may use form F700-168-000 Parent Authorization Summer Work  



Form
F700-002-000
 
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
 
Record Keeping Provisions - Employment Standards

This form is for employers to use to keep records on every employee.



Form
F700-009-000
 
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
 
Application for Farm Labor Contractor License

Used to apply or renew a license.



Form
F700-014-000
 
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
 
Washington State Prevailing Wage Law

Booklet: Contains the prevailing wage laws (RCWs) and rules (WACs) as well as plain language descriptions and contact information.



Publication
F700-032-000
 
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
 
Minimum Wage Law Exemptions

Covers exemptions to Washington state minimum wage law.



Publication
F700-051-000
 
Employer Rights - Wages Paid

Covers penalties for employer wage violations. Once stock runs out in warehouse, this form will be internet only.



Form
F700-058-000
 
Farm Labor Contractor Assignment of Account or Time Deposit

Farm Labor Contractor assignment of account or tme deposit for employee



Form
F700-060-000
 
Certified Project Payroll

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.



Form
F700-065-000
 
Farm Labor Contractors Bond

Notarized farm labor contractors bond coverage.



Form
F700-066-000
 
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: 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
 
Variance Application - For exceptions from specific rules governing employment of minors.

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



Form
F700-076-000
 
Washington State OverTime Law

Covers compensation for employees in Washington State working overime.



Publication
F700-079-000
 
Nonagricultural Employment of Minors Chapter 296-125 WAC

Nonagricultural Employment of Minors Chapter 296-125 WAC



Manual
F700-084-000
 
Agricultural Employment Standards - Chapter 296-131 WAC (Spanish) Estándares de Trabajo Agrícola

Agricultural Employment Standards - Chapter 296-131 WAC (Spanish) Estándares de Trabajo Agrícola



Manual
F700-085-999

Alt Language(s):
Inglés
 
Farm Labor Contractor Registration

Fact Sheet: Explains how to get a farm labor contractor license in order to operate legally as a farm labor contractor in Washington State.



Publication
F700-088-000

Alt Language(s):
Español
 
Farm Labor Contractor Registration-Spanish (Registro para un Contratista de Trabajadores Agrícolas)

Fact Sheet: Explains how to get a farm labor contractor license in order to operate legally as a farm labor contractor in Washington State.



Publication
F700-088-999

Alt Language(s):
Inglés
 
Variance Application - Employment Standards

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



Form
F700-089-000
 
Minimum Wage Law - Truck Drivers

Record keeping provisions and overtime for truck & bus drivers.



Publication
F700-095-000
 
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
 
Washington State Deduction Laws

Deductions for current & terminated employees and employer liability for paying less than required.



Form
F700-097-000
 
Internal Revenue Service Tax Compliance Certification

Form to gain Internal Revenue Service Tax Compliance Certification for registered Farm Labor Contractors. Now includes IRS form 8821 Tax Information Authorization.



Form
F700-098-000
 
Department of Employment Security Tax Compliance Certification

Form to gain Department of Employment Security Tax Compliance Certification for registered Farm Labor Contractors.



Form
F700-099-000
 
Department of Revenue Tax Compliance Certification

Form to gain Department of Revenue Tax Compliance Certification for registered Farm Labor Contractors.



Form
F700-100-000
 
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
 
Farm Labor Contractor Complaint Form

Used to file a complaint against a Farm Labor Contractor, landowner, employer, or other where a possible infraction is concerned.



Form
F700-109-000

Alt Language(s):
Español
 
Formulario de Queja en Contra de un Contratista de Trabajores Agrícolas (Farm Labor Contractor Complaint)

Used to file a complaint against a Farm Labor Contractor, landowner, employer, or other where a possible infraction is concerned.



Form
F700-109-999

Alt Language(s):
Inglés
 
Farm Labor Contractor Checklist

Farm Labor Contractor's Checklist to ensure compliance.



Form
F700-112-000

Alt Language(s):
Español
 
Lista de Comprobacion para un Contratista de Trabajores Agrícolas (Farm Labor Contactor Checklist)

Farm Labor Contractor's Checklist to ensure compliance.



Form
F700-112-999

Alt Language(s):
Inglés
 
Employing Children Under Age 14 in Non-Agricultural Jobs

Fact sheet: Explains when employers can and cannot employ minors under age 14 in non-agricultural jobs. Details the process for obtaining court permission when hiring minors under 14 is allowed.



Publication
F700-117-000
 
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
 
Court Form Granting Permission for Employment of Minors

Form from Court Granting Permission for Employment of Minors to the employer.



Form
F700-119-000
 
Application for Special Certificate to Employ at A Subminimum Wage Rate

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



Form
F700-120-000
 
Application for House to House Sales Sales Employer Registration Certificiate

Used by employers to register as employing minors who will be engaged in house-to-house sales, as required by WAC 296-125-024, with Labor and Industries.



Form
F700-121-000
 
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
 
Summary of Agricultural Employment Regulations and Farm Contractor Requirements

This summary is on employment laws relating to the agricultural industry.



Publication
F700-124-000
 
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
 
Interested Party Checklist for the Filing of Prevailing Wage Complaints

Checklist used for the filing of Prevailing Wage Complaints by "Interested parties" ONLY.



Form
F700-129-000
 
Seasonal Group Variance Application

Used for Exceptions from the Hours of Work for Minors for Seasonal work. This form is a word document and can be completed electronically. If you have an electronic signature, you may use it on the form. You may save the form and send it as an attachment via email to the address at the top of the form, i.e., teensafety@Lni.wa.gov. If you do not have an electronic signature, complete the form, save it in your files, print it, sign it and fax or mail it to the address at the top of the form. Variance Application forms may be faxed to (360) 902-5300. If you would like the approved Variance Certificate faxed back to your business, please state so on your cover sheet.



Form
F700-135-000
 
Congratulations! You've been approved to hire minors
Card: Reminds employers of special work rules for employees under age 18. Lists key points and provides a Web address for where to find more detailed information. Sent to all employers who obtain a minor work permit endorsement on the master business license.

Publication
F700-136-000
 
Safety Steps for Supervisors and Employees in Restaurants
Fact Sheet: A useful summary of the responsibilities both employers and employees share for a safe workplace. This can be shared with new employees during their initial orientation.

Publication
F700-139-000
 
Restaurant Employee Safety Orientation Checklist
Fact Sheet: Download this checklist to help with the safety orientation of new restaurant employees.

Publication
F700-140-000
 
Request for Assistance in Obtaining Certified Payroll Records
Used to request copies of Certified Payrolls for prevailing wage projects.

Form
F700-141-000
 
Hiring Teens this Summer? - Spanish (¿Piensa contratar adolescentes este verano?)
Flier: Provides important information about hiring teens, including extra safety precautions, as well as legal requirements regarding minor work endorsement, hours and prohibited duties. Provides telephone, e-mail and Web contacts for more information.

Publication
F700-142-999

Alt Language(s):
Inglés
 
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
 
Protected Leave Complaint

For leave from work complaints: Download and complete a Protected Leave Complaint form (F700-144-000)



Form
F700-144-000

Alt Language(s):
Español
 
Protected Leave Complaint Form - Spanish - Queja sobre el Permiso de Ausencia Protegida

Para quejas de ausencia del trabajo: Descargue y complete un formulario de Queja sobre permiso de ausencia protegida (F700-144-999)



Form
F700-144-999

Alt Language(s):
Inglés
 
Youth in Construction - English/Spanish (Adolescentes en construcción)
Booklet/pamphlet: Explains the limits on work teens under age 18 can perform in the construction industry, discusses the importance of training and emphasizes safety. Includes a checklist of "do's" and "don'ts" for employers, plus other resources.

Publication
F700-145-909
 
Prevailing Wage Complaint and Instructions

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.



Form
F700-146-000

Alt Language(s):
Español
 
Prevailing Wage Complaint Instructions - Spanish - Instrucciones para el Registro de una Queja Sobre Salario Prevaleciente

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



Form
F700-146-999

Alt Language(s):
Inglés
 
Farm Labor Contractor Certified Payroll
Farm Labor Contractor Certified Payroll

Form
F700-147-000
 
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
 
Wage-and-Hour Questions Employers Often Ask

Fact sheet: Provides answers to questions related to pay requirements, deductions from pay, hiring a teen worker, employee uniforms and access to personnel file. Includes contact information if an employer needs assistance with a specific situation.



Publication
F700-150-000
 
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
 
Avoid Liability for Your Farm Labor Contractor's Unpaid Debits (English/Spanish) / Evite su Obligación por las Deudas no Pagadas de su Contratista de Trabajadores Agrícolas

Fact sheet: Explains how employers could be liable for unpaid workers' compensation premiums, unpaid wages, damages and civil penalties when hiring a farm labor contractor. Outlines ways to protect against potential liability.



Publication
F700-154-909
 
Application for Farm Internship

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.



Form
F700-158-000
 
Statement of Intent to Pay Prevailing Wages Addendum A

Please use this addendum to list additional Crafts/Trades/Occupations when you need to add more Crafts/Trades/Occupations than the Statement of Intent to Pay Prevailing Wages form can accommodate. Addendum A is for form F700-029-000.



Form
F700-160-000
 
Affidavit of Wages Paid Addendum A Additional List of Crafts

Please use this addendum to list additional Crafts/Trades/Occupations when filing an Affidavit of Wages of Paid and you need to list more Crafts/Trades/Occupations than the Affidavit of Wages Paid form can accommodate. This is the addendum A to form F700-007-000.



Form
F700-161-000
 
Affidavit of Wages Paid Addendum C Additional Information

Please use this addendum to provide any additional information you want to communicate to L&I when you file an Affidavit of Wages of Paid. Addendum C is for form F700-007-000.



Form
F700-162-000
 
Statement of Intent to Pay Prevailing Wages Addendum C

Please use this addendum to provide any additional information you want to communicate to L&I when you file a Statement of Intent to Pay Prevailing Wages. Addendum C is for form F700-029-000.



Form
F700-163-000
 
Student Learner Variance Application

Employer uses this application form for requesting a variance to employment regulations for minors enrolled in a work-based learning placement. It can be used for individual or multiple minors for the same employer.



Form
F700-166-000
 
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
 
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
 
Farm Labor Contractor Application/Renewal Packet

This is the packet you would complete to register as a farm labor contractor.



Form
F700-170-000
 
How To Calculate Your Wage in Agriculture

Fact/Information sheet: Shows piece rate workers how to calculate their wages to check if they are being paid minimum wage.



Publication
F700-171-000

Alt Language(s):
Español
 
Cómo calcular su salario en agricultura - (English) How To Calculate Your Wage in Agriculture

Hoja de información: Muestra a los trabajadores por contrato como calcular sus salarios y verificar si le están pagando salario mínimo.



Publication
F700-171-999

Alt Language(s):
Inglés
 
Help for Crime Victims/Ayuda para Víctimas de Crimen (English/Spanish)

Pamphlet/booklet: Answers questions about Washington State's Crime Victims Compensation Program, who may be eligible for benefits and how to apply.



Publication
F800-006-909
 
Statement for Crime Victims Mental Health Services

Used by the Crime Victims Compensation Program providers for reimbursement of Mental Health Services.



Form
F800-025-000
 
Application to Reopen Crime Victim Claim Due to Worsening of Condition

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



Form
F800-031-000

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

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



Form
F800-031-999

Alt Language(s):
Inglés
 
Help for Crime Victims (large poster)
Poster: Provides contact information for the Crime Victims Compensation Program. Intended for display in health-care, criminal-justice and social-service organizations that assist crime victims. The size is 11" X 17" if ordered from the Crime Victims Compensation Program. If you print from the Web, the poster will be 8.5" X 11".

Poster
F800-041-000

Alt Language(s):
Español
 
Help for Crime Victims (large poster) - Spanish (Ayuda para Victimas de Crimen)
Poster: Provides contact information for the Crime Victims Compensation Program. Intended for display in health-care, criminal-justice and social-service organizations that assist crime victims. The size is 11" X 17" if ordered from the Crime Victims Compensation Program. If you print from the Web, the poster will be 8.5" X 11".

Poster
F800-041-999

Alt Language(s):
Inglés
 
Application for Benefits - Crime Victims

Used by victims of a crime in Washington State to receive benefits for time lost from work, loss of financial support, medical or mental health treatment. The Spanish version of the instructions are online as F800-042-999.



Form
F800-042-000

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

Instructions in Spanish to complete the English form F800-042-000 Application for Crime Victim benefits. The form is used by victims of a crime in Washington State to receive benefits for time lost from work, loss of financial support, medical or mental health treatment. This 12-10 version is internet only.



Form
F800-042-999

Alt Language(s):
Inglés
 
Travel Reimbursement Request - Crime Victims
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.

Form
F800-049-000
 
Master Level Counselor Provider Account Application for Crime Victims

Master Level Counselor Provider Account Application for Crime Victims



Form
F800-053-000
 
Request for Survivor Counseling Benefits (English/Spanish) Solicitud para Beneficios de Apoyo para los Sobrevivientes  

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



Form
F800-057-909
 
Know What to Expect: How Recoveries and Settlements May Impact Your Crime Victim Claim

Pamphlet and form: Explains third-party liability, recoveries and settlements. A crime victim or the Crime Victims Compensation Program may pursue monetary restitution from someone who caused or contributed to a crime victim's injury. Explains the purpose of the form and why individuals who file a crime victims claim are required to complete it.



Publication
F800-074-000
 
Statement for Crime Victim Miscellaneous Services

Used by the provider or supplier for reimbursement of the following services - dental, glasses, home health, nursing home serivces, medical equipment, prosthetics-orthotics, transportation, vocational, retraining and other.



Form
F800-076-000
 
Crime Victims Compensation Program Initial Response and Assessment: Form I
Used by the clinical provider to get approval to see a victim for six sessions or less. If more than six sessions, please complete Form II (F800-081-000).

Form
F800-080-000
 
Crime Victims Compensation Program Initial Response and Assessment: Form II

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



Form
F800-081-000
 
Crime Victim Compensation Program Sexual Assault Exam Report

A form used by physicians, hospitals and clinics to provide information and reporting to the Crime Victims Compensation Program.



Form
F800-098-000
 
Billing Guidelines for Sexual Assault Examinations: Crime Victims Compensation Program

Provides information health-care providers need to bill the Crime Victims Compensation Program for medical services.



Manual
F800-100-000
 
Helping Providers Understand the Crime Victims Compensation Program
Fact sheet: Answers questions doctors and mental health counselors may have about the Crime Victims Compensation Program and billing for services. Also suggests steps these providers can take to speed up reimbursement.

Publication
F800-102-000
 
Help for Crime Victims (small poster)
Poster: Provides contact information for the Crime Victims Compensation Program. Intended for display in health-care, criminal-justice and social-service organizations that assist crime victims. This poster is 8.5" X 11."

Poster
F800-104-000

Alt Language(s):
Español
 
Help for Crime Victims (small poster) - Spanish (Ayuda para Victimas de Crimen)
Poster: Provides contact information for the Crime Victims Compensation Program. Intended for display in health-care, criminal-justice and social-service organizations that assist crime victims. This poster is 8.5" X 11."

Poster
F800-104-999

Alt Language(s):
Inglés
 
Mental Health Fee Schedule and Billing Guidelines

Manual: This manual is for providers who bill the Crime Victims Compensation Program for mental health services for crime victims.



Manual
F800-105-000
 
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
 
Your Independent Medical Exam (IME): Crime Victims Compensation Program
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.

Publication
F800-115-000
 
Crime Victims Direct Entry Billing Manual
Instructions for completing a Direct Entry bill to submit to the Crime Victims Compensation Program. Direct entry allows you to submit or adjust bills using a free online billing form through Provider Express Billing (PEB).

Manual
F800-118-000
 
Ten Safe Handling Hints for Knives
Shows ten tips on handling a knife safely. Get poster printing tips.

Poster
FSP0-903-000
 
Preventing Slips and Falls
Information on how to prevent slips and falls with your footwear, housekeeping and also some general awareness tips. Get poster printing tips.

Poster
FSP0-904-000
 
Stay Clear of Suspended Loads
Pictures a guy under a suspended wooden carton. Get poster printing tips.

Poster
FSP0-908-000
 
Standard Hand Signals for Cranes

Poster: Displays proper hand signals for directing crawler, locomotive and truck crane operators. Please order from L&I or print on 11" X 17" paper.



Poster
FSP0-910-000
 
Poster - An Unprotected Trench is an Early Grave

Poster: Trench safety information for employers. Features tips to prevent cave-ins, and proper inspection proceedures. Get poster printing tips.



Poster
FSP0-912-000
 
The Best Accident Insurance - To observe all safety regulations
Picture of a guy with Saftey Policy and Rules in his hand. Get poster printing tips.

Poster
FSP0-915-000
 
Four Steps to Proper Lifting
Pictures of a person lifting a large box correctly along with tips on how to correctly lift a large item safely. Get poster printing tips.

Poster
FSP0-918-000
 
Robberies and Abusive Customers: Tips for Preventing Injuries-Spanish (Robos y Clientes Abusivos: Consejos para Prevenir Lesiones)

Tips on handling cash and how to have a safer restaurant or retail environment. Get poster printing tips.



Poster
FSP0-919-999

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

Poster
FSP0-928-999

Alt Language(s):
Inglés
 
Always Wear Eye Protection
Picture of a large eye with some content on when to use eye protection. Get poster printing tips.

Poster
FSP0-940-000

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

Poster
FSP0-940-999

Alt Language(s):
Inglés
 
Always Wear Eye Protection

Sticker: 7.25 inches X 4.25 inches.



Sticker
FSP0-941-000
 
Ladder Safety
Picture of a ladder with safety tips on the rungs. Get poster printing tips.

Poster
FSP0-951-000
 
Sticker - Danger! Minimum Clearance - Logging

Sticker size = 8.25 x 6.



Sticker
FSP0-972-000
 
Danger! Minimum Clearance for Counter Balance - Construction

Sticker: 30 inches long.



Sticker
FSP0-974-000
 
Safe Ways - Fork Lift Safety
Safety tips on using a fork lift. Get poster printing tips.

Poster
FSP0-978-000
 
Grinding Wheel - Prevent Accidents

Sticker size 4"x3"



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

Poster
FSP1-004-000

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

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



Poster
FSP1-004-999

Alt Language(s):
Inglés
 
Well...My Daddy Wears 'Em
Little boy wearing his daddy's hard hat, eye protection, gloves and boots. Get poster printing tips.

Poster
FSP1-010-000
 
Danger, Workers Above-Spanish (Peligro - Trabajadores en el Nivel Superior)

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



Poster
FSP1-012-999

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

Poster
FSP1-013-000

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

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



Poster
FSP1-013-999

Alt Language(s):
Inglés
 
Cartel - PELIGRO

Large lettering: PELIGRO



Poster
FSP1-030-999

Alt Language(s):
Inglés
 
Walk, Don't Run
Timeless reminder to walk, don't run, showing a banana peel. Get poster printing tips.

Poster
FSP1-051-000
 
Know Your Lockout Tagout Safety Procedures
Poster: Visual reminder you can print for posting in appropriate workplaces. Two options available for download and/or printing.

Poster
FSP1-063-000
 
Master Business Application

Link is to the Master Business License online form: Required for employers who hire minors and is obtained by completing the Master Business Application. Also available from L&I warehouse.



Form
BLSF-700-028
 
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
 
Program Equal Employment Opportunity Activity Documentation

Used to record individual equal employment opportunity activities conducted by Apprenticeship Programs.



Form
F100-012-000
 
On-the-Job Training Agreement Card
This card is used by an OJT Apprenticeship program ONLY. To receive this form, you must contact the Apprenticeship Section.

Form
F100-019-000
 
Request for Change of Status - Apprenticeship/Training Agreements and Training Agents

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.



Form
F100-021-000
 
The Apprenticeship Advantage: Earn While You Learn!
Fact sheet: Introduces apprenticeship to younger people. Explains the benefits of apprenticeship, a program of study where apprentices earn wages while learning a skilled profession. Includes contact information for L&I's apprenticeship coordinators around the state.

Publication
F100-022-000
 
Request for Revision of Committee

Used to request revision of committees to include changing the title of the standards, sub-committee members, and committee members.



Form
F100-031-000
 
Application for Apprenticeship

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.



Form
F100-033-000
 
Washington State Apprenticeship Programs Catalog
Book: Provides an overview of apprenticeship, explains general requirements, lists the apprenticeship programs in Washington State and, and provides contact information. The version available online may contain more up-to-date information than the June 2012 printed edition.

Publication
F100-041-000
 
Apprenticeship Applicant Register
Example: Used for tracking applicants for an apprenticeship program. Registered Apprenticeship Programs use their own forms.

Form
F100-045-000
 
Journey Level Wage Rate from which apprentices' wages rates are computed.

Used to submit the Journey-level wage rate from which the apprentices' wage rate is computed. Form must be submitteed at least annually or sooner if the rates change.



Form
F100-050-000
 
Related Supplemental Instruction Hours

Used by Apprenticeship programs to submit related instruction hours to L&I Apprenticeship section. It is preferred that programs use the combined RSI/OJT reporting form. RSI Hours must be reported quarterly.



Form
F100-228-000
 
On-The-Job Training Work Hours

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



Form
F100-229-000
 
Request for Cancellation of Program
Used for cancelling an apprenticeship program.

Form
F100-303-000
 
Authorization of Signature

This gives individuals other than the Secretary or Chairman authorization to sign ALL Papers or just Registration Cards. Must be signed by a quorum of the Apprenticeship Committee.



Form
F100-500-000
 
Apprenticeship Transfer Agreement

Used to allow an apprentice to transfer from a Washington State Registered apprenticeship program to another Washington State Registered program.



Form
F100-503-000
 
Request for Recognition of Apprenticeship Committee

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



Form
F100-504-000
 
Apprenticeship Complaint (Not for Apprenticeship Appeals)

Used to file a complaint on a apprenticeship program, committee, training agent, etc. NOT be used by Apprentices appealing Committee Decisions.



Form
F100-505-000
 
Approved Training Agent

Used to allow an employer to train apprentices as part of a Registered Apprenticeship program.



Form
F100-508-000
 
Instructor's Report of Accident / Incident

This form must be submitted to L&I's Apprenticeship Section by the Instructor at the time of the incident and the appropriate Apprenticeship Program within 5 days of an accident/incident of an apprentice/trainee during Related Supplemental Instruction (RSI).



Form
F100-509-000
 
Request for Cancellation of New Apprenticeship Committee
To request a cancellation of a new apprenticeship committee which never has a "Request for New Standards" approved by the WSATC

Form
F100-510-000
 
Notice to Attending Physician of Apprentice / On-the-Job-Training Accident / Incident

A notice to the attending physician that the individual is a Registered Apprentice and to attach this form to the Accident Report of Industry Injury or Occupational Disease (F242-130-000).



Form
F100-511-000
 
Registered Apprenticeship Program Address/Mailing Information Update

Used by the Registered Apprenticeship Program to update their address or mailing information. (Note: This DOES NOT update your program standards information.) You should ensure that your address information in the Standards is correct.



Form
F100-512-000
 
Equal Employment Opportunity (EEO) Resource & Referral Update Form

Used by an organization to get on the Apprenticeship Program equal opportunity resources list or use to update their information on the list.



Form
F100-513-000
 
Log of Good Faith Effort Documentation

This is for Registered Apprenticeship Programs to record Good Faith Effort activities in accordance with their Registered Apprenticeship Standards (Equal Employment Opportunity Plan)



Form
F100-515-000
 
Notice of Contest or Objection to Proposed Standards of Apprenticeship

Used by competitor to contest or object to a proposed standards of apprenticeship, new occupation or revised geographical area. Submit this form at least 20 days prior to a Council meeting.



Form
F100-516-000
 
Apprenticeship Related Supplemental Instruction (RSI) Plan Review Glossary of Terms
Glossary of terms used with Apprenticeship Related Supplemental Instruction (RSI) Plan Review form and RSI Plan.

Form
F100-519-000
 
Apprenticeship Related Supplemental Instruction (RSI) Plan Revew Review Criteria
Describes the process for getting approval of new or revised RSI for new apprenticeship programs/standards/occupations.

Form
F100-521-000
 
Training Agent Agreement and Understanding of Equal Employment Opportunity (EEO) Requirements of the Apprenticeship Committee - Alternate Selection Process

This should be signed by all employers who are Training Agents with Apprenticeship Programs that use an Alternate Selection Process. This also explains their obligations and rights as part of this process.



Form
F100-523-000
 
Apprenticeship Advantage poster
Poster: Introduces apprenticeship, especially for younger people. Promotes the benefits of apprenticeship and includes contact information to learn more.

Poster
F100-526-000
 
Apprenticeship Committee Representative Qualification Information Experience & Education History

Supplys the experience and education history of new committee members to ensure that they are qualified to be committee members. Used for New Standard submissions only.



Form
F100-528-000
 
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
 
A Parents' Guide to Apprenticeships
Booklet: Designed specifically for parents, this booklet provides an overview of apprenticeship. Topics include the benefits of apprenticeship, career options, requirements, how to apply and contact information.

Publication
F100-530-000
 
Comparing Career Pathways

Fact sheet: Assists high school students and their parents by comparing the benefits of registered apprenticeship to a traditional university or college program. Compares wages, costs, and length of study.



Publication
F100-531-000
 
Apprenticeships For Tribal Members

 

Brochure: Designed for tribal members, this brochure provides an overview of apprenticeship. Topics include the benefits of apprenticeship, career options, how to apply and contact information.

 



Publication
F100-532-000
 
Registered Apprenticeship in the Construction Industry

Brochure: Designed for construction business employers who are interested in hiring apprentices. Includes answers to common questions, how to hire apprentices, the benefits of apprenticeship, testimonials, and contact information.



Publication
F100-533-000
 
Access Authorization for External Access to Apprenticeship Registration and Tracking System (ARTS)

Form must be filled out to request access to Apprenticeship Registration and Tracking System (ARTS).



Form
F100-535-000
 
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
 
Request for Public Records

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.



Form
F101-009-000
 
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
 
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
 
Your Privacy Is Important to Us (English/Spanish)
Fact sheet: Serves as L&I's official privacy notice. States how L&I may use and share the pesonal information it collects. It also informs the public how they can file a complaint if they believe L&I has misused or inappropriately disclosed their personal information.

Publication
F101-055-909
 
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
 
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
 
2005 Annual Report - Department of Labor & Industries

Provides a statistical overview of results achieved in fiscal year 2005 (July 1, 2004, through June 30, 2005), budget information and a narrative introduction to the Department of Labor and Industries.



Publication
F101-068-000
 
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
 
2006 Annual Report - Department of Labor & Industries
Provides a statistical overview of results achieved in fiscal year 2006 (July 1, 2005, through June 30, 2006), budget information and a narrative introduction to the Department of Labor & Industries.

Publication
F101-078-000
 
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
 
2007 Annual Report - Department of Labor & Industries

Provides a statistical overview of results achieved in fiscal year 2007 (July 1, 2006, through June 30, 2007), budget information and a narrative introduction to the Department of Labor & Industries.



Publication
F101-080-000
 
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
 
Doing Business with the State of Washington: A Guide to Washington State Bid Opportunities
Pamphlet/booklet: Provides an overview of bid opportunities and processes for Washington State government with specific contact information for the Department of Labor & Industries.

Publication
F101-087-000
 
Small Business Liaison Info Card
Introduces L&I's Small Business Liaison and the services provided, along with information on subscribing to the e-newsletter, L&I News for Small Business.

Publication
F101-088-000
 
2008 Annual Report - Department of Labor & Industries

Provides a statistical overview of operations in fiscal year 2008 (July 1, 2007, through June 30, 2008), budget information and a summary of accomplishments during the fiscal year.



Publication
F101-089-000
 
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
 
Challenging Times Demand Our Best
Booklet: Describes how L&I is making changes, both big and small, to better serve our customers and operate efficiently. Three areas of focus are fighting fraud, putting customers first and cutting costs. Features stories about three customers L&I has helped.

Publication
F101-095-000
 
Strategic Plan
Booklet: Explains the strategic direction of the Department of Labor & Industries. Includes a message from the director, goals, objectives and strategies.

Publication
F101-099-000
 
Field Operations-Regional Boundaries and Office Information

Fact sheet: Shows which L&I region serves which counties and the location of offices. Side Two lists the address and telephone number for each office.



Publication
F101-100-000
 
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
 
Challenges and Change: Managing and Innovating through The Great Recession — L&I from 2005-2012

Booklet: Discusses the impact of the Great Recession on L&I’s programs and highlights accomplishments from 2005 to 2012.



Publication
F101-102-000
 
L&I Facility Use Application and Agreement for Government Agencies
Use this form if you are a government agency wanting to use the L&I facility located at 7273 Linderson Way SW; Tumwater, WA. (4 pages)

Form
F120-097-000
 
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
 
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
 
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
 
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
 
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
 
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
 
Application for Self-Insurance Certification

Used by employers to apply for self-insurance certification.



Form
F207-001-000
 
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-Insurance Report of Occupational Injury or Disease (SIF-5)

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



Form
F207-005-000
 
Quarterly Report for Self-Insured Business

Form used to submit Quarterly Report. If you need a copy of this form to complete your quarterly report, please contact Certification Services at 360-902-6867.



Form
F207-006-000
 
Quarterly Statement of Supplemental Benefits Paid for Self-Insured Employers

Used by self-insured employers to report their quarterly statement of supplemental benefits.



Form
F207-011-000
 
Quarterly Statement of Supplemental Benefits Instructions

Instructions for filling out the quarterly statement of supplemental benefits.



Form
F207-011-111
 
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
 
Special Escrow Agreement
Used by self-insured employer as a means to provide surety. This is an agreement between the self-insurer and the bank to hold these securities in trust as collateral for its self-insured program.

Form
F207-039-000
 
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
 
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-Insurer's Bond - Existing Liabilities
Used to provide collateral for a self-insured program.

Form
F207-068-000
 
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
 
Claim Suppression Complaint

An injured worker may submit this form if their employer has suppressed their right to file an injury claim.



Form
F262-024-000

Alt Language(s):
Español
 
Queja por Suprimir un Reclamo - Spanish - Claim Suppression Complaint
An injured worker may submit this form if their employer has suppressed their right to file an injury claim.

Form
F262-024-999

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
 





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