Forms and Publications

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La resolución de su reclamo con L&I podriá ser su mejor opción: Una opción para trabajadores lesionadosde 50 años de edad o más  


Publication
F240-003-999

World Language(s):
Inglés
 

Permanezca en el Trabajo: Una Solución Factible  


Publication
F243-006-999

World Language(s):
Inglés
 
¿Lesionado por un tercero? Usted tiene opciones legales


Form
F249-008-999

World Language(s):
Inglés
 
¿Lesionado por un tercero? Usted tiene opciones legales


Publication
F249-008-999

World Language(s):
Inglés
 
¿Necesita un doctor?


Publication
F160-006-999

World Language(s):
Inglés
 
3 Things to Know about L&I's Medical Provider Network


Publication
F242-406-000

World Language(s):
Español
 
A Guide to Workers' Compensation Benefits For Employees of Self-Insured Businesses


Publication
F207-085-000

World Language(s):
Español
 
Accountability Agreement


Form
F280-016-000
 
Actions at Law for Injury or Death - RCW 51.24


Form
F249-031-000

World Language(s):
Español
 
Activity Prescription Form (APF)


Form
F242-385-000
 
Acuerdo de propiedad de herramientas y equipo para el plan de formacion profesional


Form
F245-351-999

World Language(s):
Inglés
 
Acuerdo entre contratistas agrícolas y trabajadores


Form
F700-046-999

World Language(s):
Inglés
 
Adaptación previa al trabajo solicitudad de ayuda


Form
F245-350-999

World Language(s):
Inglés
 
Address Change Request for Pensioners


Form
F242-107-000

World Language(s):
Español
 
Adolescentes en el trabajo: información para empleadores, padres y adolescentes


Publication
F700-022-999

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


Form
F242-395-000

World Language(s):
Español
 
Agreement - Farm Labor Contractors and Workers


Form
F700-046-000

World Language(s):
Español
 
Agreement of Assumption and Guarantee of Workers' Compensation Liabilities (Certified Self-Insurer)


Form
F207-040-001
 
Agreement of Assumption and Guarantee of Workers' Compensation Liabilities - Application of Certification


Form
F207-040-000
 
Amendment of Irrevocable Standby Letter of Credit


Form
F207-112-111
 
An Employer's Intro to L&I


Publication
F101-101-000
 
Annual Supplemental Surety Information


Form
F207-125-000
 
Application for Benefits - Crime Victims


Form
F800-042-000

World Language(s):
Español
 
Application for Benefits - Homicide Claims


Form
F800-120-000

World Language(s):
Español
 
Application for Construction Contractor Registration


Form
F625-001-000
 
Application for Elective Coverage - Sole Proprietor, Partners, For-Profit Corporate Officers, or Member/Managers of Limited Liability Company (LLC)


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


Form
F213-112-000
 
Application for Exclusion/Inclusion - Mandatory Coverage (Family Farm)


Form
F213-113-000
 
Application for Group Retrospective Rating


Form
F250-004-000
 
Application for Inclusion on List of Eligible Attorneys


Form
F249-017-000
 
Application for Limited Elective Coverage for Licensed Pony Riders


Form
F250-026-000
 
Application for out of State Supplemental Reporting


Form
F212-234-000
 
Application for Pension Benefits by Spouse or Children


Form
F242-391-000

World Language(s):
Español
 
Application for Self-Insurance Certification


Form
F207-001-000
 
Application for Structured Settlement


Form
F240-002-000

World Language(s):
Español
 
Application for Loss of Earning Power (LEP) - Compensation Medical


Form
F242-208-000

World Language(s):
English/Español
Español
 
Application for Loss of Earning Power Compensation Medical / Solicitud para compensación por reducción de ingresos (médicos) (English/Spanish)


Form
F242-208-909

World Language(s):
Inglés
Español
 
Application for Loss of Earning Power Vocational / Solicitud para compensación por reducción de ingresos (Vocacionales) (English/Spanish)


Form
F242-209-909

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


Form
F242-079-000

World Language(s):
English/Español
Español
 
Application to Reopen Crime Victim Claim Due to Worsening of Condition


Form
F800-031-000

World Language(s):
Español
 
Application for Loss of Earning Power (LEP) - Vocational


Form
F242-209-000

World Language(s):
English/Español
Español
 
Approved Independent Medical Examiner (IME) Update


Form
F245-051-000
 
Assessment Eligible Quality Assurance Review Form


Form
F280-008-000
 
Attending Doctor's Handbook


Publication
F252-004-000
 
Authorization for Deposit of Payments / Autorización para depósitos de pagos (English/español)


Form
F242-174-909

World Language(s):
Inglés
 
Authorization for Deposit of Payments


Form
F242-174-000

World Language(s):
English/Español
 
Authorization to Release Claim Information


Form
F101-010-000

World Language(s):
Español
 
Authorization to Release Information


Form
F262-005-000

World Language(s):
Español
 
Autorización de método de pago


Form
F120-211-999
 
Autorización para entregar información


Form
F262-005-999
 
Autorización para proveer información de reclamos


Form
F101-010-999

World Language(s):
Inglés
 
Autorization del trabajador para obtener registros de trabajos despachados por el sindicato


Form
F242-410-999

World Language(s):
Inglés
 
Avoid Liability for Your Farm Labor Contractor's Unpaid Debits / Evite su obligación por las deudas no pagadas de su contratista de trabajadores agrícolas (English/español)


Publication
F700-154-909
 
Avoid Liability for Your Subcontractor's Unpaid Workers' Comp Premiums


Publication
F262-262-000

World Language(s):
Español
 
Ayuda para trabajadores lesionados de empresas autoaseguradas


Publication
F207-201-999

World Language(s):
Inglés
 
Ayuda para víctimas de crimen (cartel grande)


Poster
F800-041-999

World Language(s):
Inglés
 
Ayuda para víctimas de crimen


Poster
F800-104-999

World Language(s):
Inglés
 
Beneficios de compensación para los trabajadores: una guía para los trabajadores lesionados


Publication
F242-104-999

World Language(s):
Inglés
 
Billing Guidelines for Sexual Assault Examinations: Crime Victims Compensation Program


Manual
F800-100-000
 
Business and Industry Category Guide


Manual
F250-025-000
 
Cómo hacer la mejor elección de tratamiento para el dolor crónico en la parte inferior de su espalda


Publication
F252-081-999

World Language(s):
Inglés
 
Cómo Registrar un Reclamo para la Compensación del Trabajador con Empresas Autoaseguradas


Form
F207-155-999

World Language(s):
Inglés
 
Cancellation of Elective Coverage - Sole Proprietors/Partner, Member of Limited Liability Company (LLC), Member of Limited Liability Partnership (LLP) or For-Profit Corporate Officers


Form
F213-004-000
 
Cancellation of Elective Coverage for Excluded Employments


Form
F213-005-000
 
Capítulo 51.24 Acciones Legales por Lesiones o Fallecimiento


Form
F249-031-999

World Language(s):
Inglés
 
Carta de intención de registro en una escuela


Form
F242-382-999

World Language(s):
Inglés
 
Certificado de cobertura - ejemplo


Form
F211-141-999

World Language(s):
Inglés
 
Certificate of Coverage - SAMPLE ONLY


Form
F211-141-000

World Language(s):
Español
 
Checklist for IME Facilities


Form
F245-421-000
 
Chemical Exposure Questionnaire Packet


Form
F242-409-000

World Language(s):
Español
 
Chronic Opioid Request Form


Form
F252-091-000
 
Claim Suppression Complaint


Form
F262-024-000

World Language(s):
Español
 
CMS 1500 Billing Manual


Manual
F245-423-000
 
CMS 1500


Form
F245-127-000
 
Comentarios Sobre el Exámen Médico Independente


Form
F245-053-999

World Language(s):
Inglés
 
Complete Stay at Work Guide for Employers, The


Publication
F243-005-000
 
Construction Contractor's Application for Workers' Compensation Account with No Workers or Hours


Form
F625-077-000
 
Construction Industry Classification Guide


Publication
F213-008-000
 
Continuación del Historial de Trabajo y de Enfermedad Ocupacional


Form
F242-071-911

World Language(s):
Inglés
 
Contract: Report By Contractor - Forest, Range & Timber Industry


Form
F213-011-000
 
Contract: Report By Landowner - Forest, Range & Timber Industry


Form
F213-010-000
 
Convenio para el tratamiento con opioides


Form
F252-095-999

World Language(s):
Inglés
 
Coverage Agreement


Form
F212-044-000
 
Crime Victim Compensation Program Sexual Assault Exam Report


Form
F800-098-000
 
Crime Victims Address Change Request


Form
F800-112-000
 
Crime Victims Compensation Physical Abuse/Neglect Exam Report


Form
F800-121-000
 
Crime Victims Compensation Program Initial Response and Assessment: Form II


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


Form
F800-082-000
 
Crime Victims Compensation Program Termination Report: Form VI


Form
F800-085-000
 
Crime Victims Compensation Program Treatment Report: Form IV


Form
F800-083-000
 
Crime Victims Compensation Program Treatment Report: Form V


Form
F800-084-000
 
Crime Victims Compensation Subacute Opioid Request Form


Form
F800-119-000
 
Crime Victims Direct Entry Billing Manual


Manual
F800-118-000
 
Crime Victims Statement for Home Nursing Services


Form
F800-070-000
 
Crime Victims Statement for Pharmacy Services


Form
F800-058-000
 
Crime Victims Provider's Request for Adjustment


Form
F800-064-000
 
Crime Victims' Statement for Compound Prescription


Form
F800-067-000
 
Cuando un ser querido fallece en el lugar de trabajo


Publication
F417-240-999

World Language(s):
Inglés
 
Cuestionario de exposición a sustancias químicas


Form
F242-409-999

World Language(s):
Inglés
 
Cuestionario para beneficios de pensión


Form
F242-393-999

World Language(s):
Inglés
 
Cuestionario sobre la pérdida del sentido auditivo en el trabajo


Form
F262-016-999

World Language(s):
Inglés
 
Cuestionario Vocacional/Historia de trabajo


Form
F280-038-999
 
CVCP Opioid Progress Report Chronic, Non-Cancer Pain and Treatment Agreement.


Form
F800-116-000
 
Declaración de derechos para dependientes del trabajador fallecido bajo el Programa de Compensación y Beneficios para Trabajadores


Form
F242-173-933

World Language(s):
Inglés
 
Declaración de derechos para padres o tutor bajo el Programa de Compensación y Beneficios para Trabajadores


Form
F242-173-922

World Language(s):
Inglés
 
Declaración de derechos para viuda(o) bajo el Programa de Compensación y Beneficios para Trabajadores


Form
F242-173-911

World Language(s):
Inglés
 
Declaración de derechos para los beneficios de un trabajador totalmente discapacitado bajo las Leyes del Seguro Industrial


Form
F242-173-944

World Language(s):
Inglés
 
Declaración de servicios de capacitación y modificación de trabajo


Form
F245-030-999

World Language(s):
Inglés
 
Declaración firmada para compensación de tiempo perdido


Form
F242-395-999

World Language(s):
Inglés
 
Declaración para servicios misceláneos


Form
F245-072-999

World Language(s):
Inglés
 
Declaration of Entitlement for Dependent of Deceased Worker Benefits Under Industrial Insurance


Form
F242-173-333

World Language(s):
Español
 
Department of Labor and Industries Home Modification Acknowledgement of Responsibilities


Form
F247-003-000

World Language(s):
Español
 
Desarrollo del plan: ¿Cuáles son mis derechos y responsabilidades? Servicios de rehabilitación vocacional


Publication
F280-018-999

World Language(s):
Inglés
 
Doctor's Worksheet for Rating Cervical and Cervico-Dorsal Impairment


Form
F252-056-000
 
Doctor's Worksheet for Rating Dorso-Lumbar & Lumbo-Sacral Impairment


Form
F252-006-000
 
Drywall Contractors


Form
F214-024-000
 
Drywall Industry - Owner/Sub-Contractor Report


Form
F212-050-000
 
Electronic Billing Authorization


Form
F248-031-000
 
Employee Misconduct: Information for Employers


Publication
F417-254-000
 
Employers' Guide to Self-Insurance in Washington State


Publication
F207-079-000
 
Employers' Guide to Workers' Compensation Insurance in Washington State


Publication
F101-002-000

World Language(s):
Español
 
Employment History Form


Form
F242-109-000

World Language(s):
Español
 
Evaluando su capacidad para trabajar: sus derechos y responsabilidades, servicios de rehabilitación vocacional


Publication
F280-017-999

World Language(s):
Inglés
 
Evaluating Retro Groups


Publication
F225-019-000
 
Financial Statement Businesses


Form
F215-040-000
 
Financial Statement Sole Proprietors and Individuals


Form
F215-039-000
 
Firm Vocational Provider Account Change


Form
F252-022-000
 
Formulario de estado de empleo (Formulario de verificación de empleo)


Form
F242-052-999

World Language(s):
Inglés
 
Formulario de historial de empleo


Form
F242-109-999

World Language(s):
Inglés
 
Formulario de opción del plan de capacitación


Form
F280-057-999

World Language(s):
Inglés
 
Formulario de verificación de empleo


Form
F800-110-999

World Language(s):
Inglés
 
Formulario para trasferencia de proveedor principal para trabajadores autoasegurados


Form
F207-114-999

World Language(s):
Inglés
 
Functional Recovery Interventions Tracking Sheet


Publication
F245-420-000
 
General Provider Billing Manual


Manual
F248-100-000
 
Guía de beneficios de Compensación para los Trabajadores: para los empleados de empresas autoaseguradas


Publication
F207-085-999

World Language(s):
Inglés
 
Guía del Empleador para el Seguro de compensación para trabajadores en el Estado de Washington


Publication
F101-002-999

World Language(s):
Inglés
 
Guía para el contratista independiente - Una guía detallada para contratar contratistas independientes en el estado de Washington


Publication
F101-063-999

World Language(s):
Inglés
 
Hearing Aid Repair/Durable Medical Equipment Provider Hotline Service Authorization Request


Form
F245-418-000
 
Hearing Aid Replacement Form


Form
F242-414-000
 
Hearing Impairment Calculation Worksheet


Form
F252-007-000
 
Hearing Services Worker Information


Form
F245-049-000
 
Help for Crime Victims (large poster)


Poster
F800-041-000

World Language(s):
Español
 
Help for Crime Victims (small poster)


Poster
F800-104-000

World Language(s):
Español
 
Help for Victims of Crime / Ayuda para víctimas de crimen (English/español)


Publication
F800-006-909
 
Historia de trabajo - pérdida de audición


Form
F262-013-999
 
Historial de trabajo (enfermedad ocupacional)


Form
F242-071-999

World Language(s):
Inglés
Español
 
Home Health Services Billing Manual


Manual
F245-424-000
 
Home Modification for Workers with Catastrophic Injuries - Questions and Answers for Contractors


Publication
F252-061-000
 
Hospital Services Billing Manual


Manual
F245-425-000
 
How to Protest a Department of Labor and Industries Decision / Cómo protestar una decisión en su reclamo del Departamento de Labor e Industrias (English/español)


Publication
F242-363-909
 
Independent Contractor Guide: A Step-by-Step Guide to Hiring Independent Contractors in Washington State


Publication
F101-063-000

World Language(s):
Español
 
Independent Medical Exam Doctor's Estimate of Physical Capacities


Form
F242-387-000
 
Independent Medical Exam Template


Form
F245-058-000
 
Independent Medical Examination (IME) Provider Exam Sites


Form
F245-047-000
 
Independent Medical Examination Fax Cover Sheet


Form
F245-383-000
 
Individual Vocational Provider Account Change Form


Form
F252-021-000
 
Industrial Insurance Discrimination Complaint


Form
F262-009-000

World Language(s):
Español
 
Injured by a third party?  


Form
F249-008-000

World Language(s):
Español
 
Injured by a third party?  


Publication
F249-008-000

World Language(s):
Español
 
Injured Workers: Leaving Washington, But Still Need Treatment


Publication
F242-412-909
 
Inquiry for Assessment of Damages


Form
F242-067-000

World Language(s):
Español
 
Instructions for completing the Workers' Compensation Employer's Quarterly Report


Form
F212-239-000
 
International Travel for Work


Publication
F242-419-000
 
Interpreter Services for Injured Workers and Crime Victims


Publication
F245-412-000

World Language(s):
Español
 
Interpretive Services Appointment Record (ISAR)


Form
F245-056-000
 
Irrevocable Standby Letter of Credit


Form
F207-112-000
 
Job Analysis Summary


Form
F252-101-000
 
Job Analysis


Form
F252-072-000
 
Job Modification Assistance Application


Form
F245-346-000

World Language(s):
Español
 
Know What to Expect: How Recoveries and Settlements May Impact Your Crime Victim Claim


Publication
F800-074-000
 
L&I Benefits for Workers Who Are Terminally Ill


Publication
F252-094-000
 
L&I Chiropractic Consultant Application


Form
F245-393-000
 
Labor and Industries Prosthetic Device Request Form


Form
F245-340-000
 
Las primas de compensación para trabajadores no pagadas por su subcontratista podrían ser su responsabilidad


Publication
F262-262-999

World Language(s):
Inglés
 
Llevando a cabo su plan vocacional: sus derechos y responsabilidades durante el plan de implementación, Servicios de rehabilitación vocacional


Publication
F280-019-999

World Language(s):
Inglés
 
Long Term Care Assessment Tool


Form
F245-377-000
 
Maritime Coverage


Form
F212-034-000
 
Maritime Coverage


Publication
F212-034-000
 
Massage Therapist: Independent Contractor or Covered Worker?


Publication
F212-248-000
 
Mechanized Logging Supplemental Quarterly Report


Form
F212-223-000
 
Medical Device Review Request


Form
F252-013-000
 
Medical Examiners' Handbook


Publication
F252-001-000
 
Memorandum of Understanding Irrevocable Standby Letter of Credit


Form
F207-113-000
 
Memorandum of Understanding


Form
F207-129-000
 
Mental Health Fee Schedule and Billing Guidelines


Manual
F800-105-000
 
Mental Health Services Fee Schedule


Publication
F245-422-000
 
Miscellaneous Services Billing Manual


Manual
F245-431-000
 
Modificacion en el trabajo solicitud de asistencia


Form
F245-346-999

World Language(s):
Inglés
 
Modificacion en la vivienda Reconocimiento de responsabilidades


Form
F247-003-999

World Language(s):
Inglés
 
Modificaciones de la vivienda para trabajadores con lesiones catastróficas – Preguntas y respuestas para contratistas


Publication
F252-061-999

World Language(s):
Inglés
 
Modificaciones de la vivienda para trabajadores con lesiones catastróficas


Publication
F252-060-999

World Language(s):
Inglés
 
Need a Doctor?


Publication
F160-006-000

World Language(s):
Español
 
Non-accredited or Unlicensed Training Provider Application Supplemental Requirements


Form
F280-045-000
 
Non-Network Provider Application


Form
F248-011-000
 
Notice of Completion of Public Works Contract


Form
F215-038-000
 
Notice of Independent Medical Exam No-Show or Late Cancellation


Form
F245-382-000
 
Notice of Occupational Disease or Infection


Form
F242-243-000
 
Notice to Employees -- If a Job Injury Occurs/Aviso a los empleados--si ocurre una lesión en el trabajo (English/español)


Poster
F242-191-909
 
Notice to Employees -- Self-Insurance / Aviso a los empleados -- Seguro industrial propio (English/español)


Poster
F207-037-909
 
Notificación de decisión de cierre con discapacidad parcial permanente para empleadores autoasegurados - DISCAPACIDAD PARCIAL PERMANENTE (PPD) - SIN TIEMPO PERDIDO (NTL)


Form
F207-165-999

World Language(s):
Inglés
 
Notificación de decisión de cierre con discapacidad parcial permanente para empleadores autoasegurados -DISCAPACIDAD PARCIAL PERMANENTE (PPD) - CON TIEMPO PERDIDO (NTL)


Form
F207-164-999

World Language(s):
Inglés
 
Notificación de decisión de cierre para reclamos únicamente médicos para empleadores autoasegurados


Form
F207-020-999

World Language(s):
Inglés
 
Notificación de decisión de cierre para reclamos de tiempo perdido para empleadores autoasegurados


Form
F207-070-999

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


Form
F242-071-000

World Language(s):
Español
 
Occupational Disease Employment History Hearing Loss


Form
F262-013-000

World Language(s):
Español
 
Occupational Disease Work History - Continuation


Form
F242-071-111

World Language(s):
Español
 
Occupational Hearing Loss Questionnaire


Form
F262-016-000

World Language(s):
Español
 
OJT Information Request and Recommendation form


Form
F280-032-000
 
On-The-Job Training (OJT) Agreement for Vocational Providers


Form
F280-039-000
 
Opioid Treatment Agreement


Form
F252-095-000

World Language(s):
Español
 
Option 1 Plan Modification Accountability Agreement


Form
F280-056-000
 
Option 2 Vocational Benefits Training Enrollment Application and Verification


Form
F280-024-000

World Language(s):
English/Español
 
Option 2 Vocational Benefits Training Enrollment Application/Solicitud y verificación del registro para capacitación de beneficios vocacionales opción 2 (English/español)


Form
F280-024-909

World Language(s):
Inglés
 
Option 2: What You Need to Know, Vocational Rehabilitation Services


Publication
F280-036-000

World Language(s):
Español
 
Out of Country Provider Application


Form
F248-361-000

World Language(s):
Español
 
Overpayment Reimbursement Fund Request Coversheet


Form
F207-212-000
 
Payment Method Authorization


Form
F120-211-000

World Language(s):
Español
 
Payroll Service Provider - Quarterly Reporting Bulk Filing Enrollment Form


Form
F248-343-000
 
Pension and Survivor Benefits in Washington State's Workers' Compensation Program / Beneficios de pensión y para sbrevivientes del Programa de compensación para trabajadores de Washington (English/español)


Publication
F242-352-909
 
Pension Benefits Questionnaire


Form
F242-393-000

World Language(s):
Español
 
Performance Based Physical Capacities Evaluation


Form
F245-023-000
 
Pharmacy Billing Manual


Manual
F245-433-000
 
Pharmacy Companion Guide


Manual
F245-400-000
 
Physical Therapy / Occupational Therapy Progress Report to Claim Managers


Form
F245-059-000
 
Physical/Occupational/Massage Therapy Provider Hotline Service Authorization Request


Form
F245-417-000
 
Plan Development Quality Assurance Review Form


Form
F280-007-000
 
Plan for and Pay Your Taxes DVD


DVD
F101-091-034
 
Plan Room and Board Cost Encumbrance


Form
F245-372-000
 
Pocket Guide to Worker Rights / Guía de bolsillo sobre los derechos del trabajador (English/español)


Publication
F101-165-909

World Language(s):
Inglés
 
Power of Attorney for Electronic Remittance Advice


Form
F248-355-000
 
Pre-Audit Questionnaire


Form
F213-177-000
 
Pre-Job Accommodation Assistance Application


Form
F245-350-000

World Language(s):
Español
 
Preauthorization Request for Services for State Fund Workers' Compensation Patients


Form
F242-397-000
 
Preferred Drug Line Prescription Authorization Request


Form
F245-419-000
 
Preferred Worker Benefit Frequently Asked Questions


Publication
F280-052-000

World Language(s):
Español
 
Preferred Worker Status Request


Form
F280-023-000
 
Preguntas frecuentes sobre el beneficio del Programa de Incentivos para Volver a Emplear Trabajadores Lesionados


Publication
F280-052-999

World Language(s):
Inglés
 
Preparing for Your Self-Insurance Audit


Publication
F207-110-000
 
Programa con Incentivos para Volver a Emplear a Trabajadores Lesionados


Publication
F280-021-999

World Language(s):
Inglés
 
Protesting Retro Adjustments


Publication
F250-027-000
 
Provider Account Application - Independent Medical Examiner (IME)


Form
F245-046-000
 
Provider Change Form for Crime Victims Compensation


Form
F800-089-000
 
Provider General Billing Manual


Manual
F245-432-000
 
Provider Payment Account Change Form


Form
F245-365-000
 
Provider's Initial Report (PIR)


Form
F207-028-000
 
Provider's Request for Adjustment


Form
F245-183-000
 
Quarterly Report for Self-Insured Business


Form
F207-006-000
 
Quarterly Reporting for Drywall


Form
F212-224-000

World Language(s):
Español
 
Quarterly Statement of Supplemental Benefits Paid for Self-Insured Employers


Form
F207-011-000
 
Queja por discriminación de Seguro Industrial


Form
F262-009-999

World Language(s):
Inglés
 
Queja por suprimir un reclamo


Form
F262-024-999

World Language(s):
Inglés
 
Quick Reference Card for Providers


Publication
F245-414-000
 
QuickFile: Workers' Compensation Quarterly Report Filing Made Easy!


Publication
F212-244-000
 
Reclamo para beneficios de pensión presentado por los dependientes


Form
F242-062-999

World Language(s):
Inglés
 
Reclamo para beneficios de pensión presentado por el cónyuge, pareja doméstica registrada o los hijos


Form
F242-056-999

World Language(s):
Inglés
 
Referral to Labor and Industries /WorkSource Partnership Services


Form
F280-046-000
 
Reforestation Contract Supplemental Report - Forest, Range and Timber Industry


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


Form
F213-015-000
 
REFUND NOTIFICATION Refunding Money to L&I to correct your account?


Form
F245-043-000
 
Regresando a trabajar es su trabajo y su futuro


Publication
F200-001-999

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


Form
F242-130-000

World Language(s):
Español
 
Request for Claim Information


Form
F101-010-111
 
Request for Survivor Counseling Benefits / Solicitud para beneficios de apoyo para los sobrevivientes (English/español)  


Form
F800-057-909
 
Resume Cover Sheet


Form
F242-418-000
 
Retraining and Job Modification Billing Manual


Manual
F245-427-000
 
Retraining Plan Option Form


Form
F280-057-000

World Language(s):
Español
 
Retrospective Rating Adjustment Protest


Form
F250-024-000
 
Sample Format for Vocational Testing Report


Form
F252-051-000
 
Sample Self-Employment Agreement


Form
F252-032-000
 
Schedule of Future Payments for the Balance of the Permanent Partial Disability Award


Form
F207-162-000
 
Se ha lesionado en el trabajo?


Publication
F242-404-999
 
Seasonal Group Variance Application


Form
F700-135-000
 
Self Insurance Continuing Education Report of Course Completion


Form
F207-191-000
 
Self Insurance Continuing Education Sponsor/Instructor Application for Course Approval


Form
F207-192-000
 
Self-Insurance Certification Questionnaire


Form
F207-176-000
 
Self-Insurance Continuing Education Application for Course Approval and Attendance


Form
F207-206-000
 
Self-Insurance Electronic Data Reporting System (SIEDRS): Enrollment Package 2.0


Publication
F207-194-000
 
Self-Insurance Medical Provider Billing Dispute form


Form
F207-207-000
 
Self-Insurance Report of Occupational Injury or Disease (SIF-5)


Form
F207-005-000
 
Self-Insurance Vocational Reporting Form


Form
F207-190-000
 
Self-Insured Employer Certificate of Excess Insurance


Form
F207-095-000
 
Self-Insured Employers' Medical Only Claim Closure Order and Notice


Form
F207-020-111

World Language(s):
Español
 
Self-Insured Employers' Permanent Partial Disability Closure Order and Notice - PPD-NTL


Form
F207-165-000

World Language(s):
Español
 
Self-Insured Employers' Permanent Partial Disability Closure Order and Notice - PPD-TL


Form
F207-164-000

World Language(s):
Español
 
Self-Insured Employers' Time Loss Claim Closure Order and Notice


Form
F207-070-000

World Language(s):
Español
 
Self-Insurer Accident Report (SIF-2)


Form
F207-002-000
 
Self-Insurer's Pension Bond


Form
F207-065-000
 
Servicios de intérprete para trabajadores lesionados y víctimas de crimen


Publication
F245-412-999

World Language(s):
Inglés
 
Settling your injured worker's L&I claim: A new option for injured workers 50 and older


Publication
F240-004-000
 
Settling your L&I claim might be right for you: An option for injured workers 50 or older


Publication
F240-003-000

World Language(s):
Español
 
SIEDRS (Self-Insurance Electronic Data Reporting System) Data Change Request


Form
F207-197-000
 
SIF-5A Cover Sheet: Wage Calculations


Form
F207-156-000
 
Small Business Liaison Info Card


Publication
F101-088-000
 
Solicitud de Acuerdo Sobre Beneficios de Compensación para Trabajadores


Form
F240-002-999

World Language(s):
Inglés
 
Solicitud de cuenta para proveedores fuera del país


Form
F248-361-999

World Language(s):
Inglés
 
Solicitud de víctimas de crimen para obtener beneficios: reclamos por homicidio


Form
F800-120-999

World Language(s):
Inglés
 
Solicitud para beneficios de pensión presentado por el cónyuge o los hijos


Form
F242-391-999

World Language(s):
Inglés
 
Solicitud para Beneficios para Víctimas de Crimen


Form
F800-042-999

World Language(s):
Inglés
 
Solicitud para cambio de dirección para pensionados


Form
F242-107-999

World Language(s):
Inglés
 
Solicitud para cambio de dirección para trabajadores lesionados


Form
F242-388-999

World Language(s):
Inglés
 
Solicitud para compensación por reducción de ingresos (médico)


Form
F242-208-999

World Language(s):
Inglés
English/Español
 
Solicitud para compensación por reducción de ingresos (Vocacional)


Form
F242-209-999

World Language(s):
Inglés
English/Español
 
Solicitud para el reembolso de gastos de viaje


Form
F245-145-999

World Language(s):
Inglés
 
Solicitud para reabrir un reclamo debido al empeoramiento de la condición 


Form
F242-079-999

World Language(s):
Inglés
English/Español
 
Solicitud para reabrir un reclamo debido al empeoramiento de la condición


Form
F800-031-999

World Language(s):
Inglés
 
Sports Player Coverage Agreement


Form
F212-242-000
 
Sports Teams and Youth Workers


Publication
F700-130-000
 
Sports Teams Coverage Agreement


Form
F212-196-000
 
Statement for Compound Prescription


Form
F245-010-000
 
Statement for Crime Victim Miscellaneous Services


Form
F800-076-000
 
Statement for Crime Victims Mental Health Services


Form
F800-025-000
 
Statement for Home Nursing Services


Form
F248-160-000
 
Statement for Miscellaneous Services


Form
F245-072-000

World Language(s):
Español
 
Statement for Pharmacy Services


Form
F245-100-000
 
Statement for Retraining and Job Modification Services


Form
F245-030-000

World Language(s):
Español
 
Statewide Payee Registration and W-9 Form Crime Victims


Form
F800-065-000
 
Statewide Payee Registration and W-9 Form


Form
F248-036-000
 
Stay at Work Expense Reimbursement Application for Employers Tools, Clothing, Training.


Form
F243-003-000
 
Stay at Work Wage Reimbursement Application for Employers


Form
F243-001-000
 
Stay at Work: A new program to help employers keep injured workers on the job--pays half the wage plus expenses


Publication
F243-006-000

World Language(s):
Español
 
Stop Work Payroll Report


Form
F262-043-000
 
Structured Settlement Income and Expense Worksheet


Form
F240-007-000
 
Student Volunteers and Workers' Compensation Coverage


Publication
F213-023-000
 
Su examen médico independiente: para empleadores de negocios autoasegurados


Publication
F207-202-999

World Language(s):
Inglés
 
Su examen médico independiente


Form
F245-224-999

World Language(s):
Inglés
 
Su examen médico independiente


Publication
F245-224-999

World Language(s):
Inglés
 
Subacute Opioid Request Form


Form
F252-097-000
 
Submission of Provider Credentials for Interpretive Services


Form
F245-055-000
 
Supplemental Agreement Third Party Pharmacy Provider


Form
F249-021-000
 
Supplemental Quarterly Report for the Drywall Industry


Form
F212-051-000
 
Tarjeta para transferencia de caso


Form
F245-037-999

World Language(s):
Inglés
 
Teens at Work: Facts for Employers, Parents and Teens


Publication
F700-022-000

World Language(s):
Español
 
Temporary Services Guide to Workers' Compensation Insurance


Manual
F213-019-000
 
Termination of Agreement (Rescission)


Form
F245-050-000
 
Third Party Recovery Worksheet


Form
F249-006-111
 
Time Encumbrance Form


Form
F245-376-000
 
Training Plan Cost Encumbrance


Form
F245-374-000
 
Transfer of Attending Provider Form for Self Insured Workers


Form
F207-114-000

World Language(s):
Español
 
Transfer of Care Card


Form
F245-037-000

World Language(s):
Español
 
Transportation Cost Encumbrance


Form
F245-375-000
 
Travel Reimbursement Request - Crime Victims


Form
F800-049-000
 
Travel Reimbursement Request


Form
F245-145-000

World Language(s):
Español
 
Tres cosas que debe conocer sobre la Red de proveedores médicos de L&I


Publication
F242-406-999

World Language(s):
Inglés
 
UB04 HCFA 1450


Form
F245-367-000
 
Understanding Your Functional Capacity Evaluation


Publication
F245-416-000

World Language(s):
Español
 
Verificación de registro en la escuela


Form
F242-055-999

World Language(s):
Inglés
 
Victim Verification Form


Form
F800-110-000

World Language(s):
Español
 
Vocational Provider Application


Form
F252-088-000
 
Vocational Questionnaire/Work History


Form
F280-038-000

World Language(s):
Español
 
Vocational Technical Stakeholder Group (VTSG) Application


Form
F280-049-000
 
Vocational Training Plan Ownership Agreement for Tools and Equipment


Form
F245-351-000

World Language(s):
Español
 
Wage-and-Hour Questions Employers Often Ask


Publication
F700-150-000
 
Washington Practitioner Application


Form
F245-411-000
 
Washington Workers Insured Out-of-State: Employer's Supplemental Quarterly Report for Workers' Compensation


Form
F212-233-000
 
What Are Your Rights as a Worker? / ¿Cuáles son sus derechos como trabajador? (English/español)


Publication
F101-061-909

World Language(s):
English/កម្ពុជា
English/한국의
English/русский
English/Vi?t
 
Work Status Form (formerly Worker Verification Form)


Form
F242-052-000

World Language(s):
Español
 
Worker Request for Union Dispatch Records


Form
F242-410-000

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


Publication
F242-104-000

World Language(s):
Español
 
Workers' Compensation Discrimination / Discriminación porque se lesionó en su trabajo (English/español)


Publication
F262-249-909
 
Workers' Compensation Employer's Quarterly Report


Form
F212-055-000
 
Workers' Compensation Filing Information


Form
F207-155-000

World Language(s):
Español
 
Workers' Compensation Record Keeping and Reporting Guides


Publication
F212-222-000
 
Workers' Compensation Requirements for the Marijuana Industry


Publication
F242-415-000
 
Your Independent Medical Exam


Form
F245-224-000

World Language(s):
Español
 
Your Independent Medical Exam


Publication
F245-224-000

World Language(s):
Español
 
Your Premium Dollars at Work (2013)


Publication
F200-022-000
 
Your Premium Dollars at Work (2014)


Publication
F200-023-000
 
Your Workers' Compensation Rate Notice - SAMPLE ONLY


Form
F225-004-000
 
¿Qué es una Evaluación de capacidad funcional?


Publication
F245-416-999

World Language(s):
Inglés
 
Acknowledgement of Security Interest


Form
F207-143-000
 
Address Change Request for Injured Workers


Form
F242-388-000

World Language(s):
Español
 
Application for Group Membership & Authorization for Release of Insurance Data


Form
F250-016-000
 
Are You an Employer Who Can Provide On-the-Job Training?


Publication
F280-033-000
 
ASC X12N 005010 EDI Transactions Companion Guide


Manual
F245-398-000
 
Assessing Your Ability to Work: Your Rights and Responsibilities


Publication
F280-017-000

World Language(s):
Español
 
Assignment of Account Agreement


Form
F207-058-000
 
Attending Provider's Return-to-Work Desk Reference


Publication
F200-002-000
 
Audit Reference Card


Publication
F214-020-000
 
Carrying Out Your Vocational Plan: Your Rights and Responsibilities During Plan Implementation


Publication
F280-019-000

World Language(s):
Español
 
Claim for Pension By Dependents


Form
F242-062-000

World Language(s):
Español
 
Claim for Pension by Spouse or Children


Form
F242-056-000

World Language(s):
Español
 
Computing Worker Hours


Publication
F214-014-000
 
Congratulations! You've been approved to hire minors


Publication
F700-136-000
 
Corporate Officers


Publication
F214-010-000
 
Crime Victims Compensation Program Initial Response and Assessment: Form I


Form
F800-080-000
 
Declaration of Entitlement for Guardian Benefits under Industrial Insurance


Form
F242-173-222

World Language(s):
Español
 
Declaration of Entitlement for Totally Disabled Worker Benefits Under Industrial Insurance


Form
F242-173-444

World Language(s):
Español
 
Declaration of Entitlement for Widow or Widower Benefits Under Industrial Insurance


Form
F242-173-111

World Language(s):
Español
 
Detenga la contratación ilegal. Si ve una situación de esta índole, denúnciela.


Publication
F625-114-999

World Language(s):
Inglés
 
Doing Business with the State of Washington: A Guide to Washington State Bid Opportunities


Publication
F101-087-000
 
Employer's Return-to-Work Guide


Publication
F200-003-000
 
Excluded and Exempt Employments


Publication
F214-013-000
 
F245-392-000 Resource Utilization Group (RUG) Residential Care Services for L&I Injured Workers (In place of MDS 3.0 beginning October 1, 2010.)


Form
F245-392-000
 
FileFast postcard handout for workers


Publication
F242-398-000
 
FileFast poster for workers


Poster
F242-399-000
 
FileFast wallet card for workers


Publication
F242-400-000
 
Five Steps to File


Publication
F212-243-000
 
Frequently Asked Questions about Job Modifications


Publication
F245-057-000
 
Getting Back to Work: It's Your Job and Your Future


Publication
F200-001-000

World Language(s):
Español
 
Getting up-to-speed on regulations for Washington businesses?


Publication
F101-174-000
 
Group vs. Individual Retrospective Rating Participation


Publication
F225-016-000
 
Help for Injured Workers of Self-Insured Businesses


Publication
F207-201-000

World Language(s):
Español
 
Helping Providers Understand the Crime Victims Compensation Program


Publication
F800-102-000
 
Home Modification for Workers with Catastrophic Injuries


Publication
F252-060-000
 
Hotline Tips for Medical Services Providers


Publication
F248-040-000
 
Independent Contractors


Publication
F214-012-000
 
Independent Medical Exam Comments


Form
F245-053-000

World Language(s):
Español
 
Individual Retrospective Rating Plan Agreement


Form
F250-003-000
 
Intent to Hire Preferred Worker


Form
F280-010-000
 
Intent to Hire Preferred Worker with Developmental Disabilities


Form
F280-011-000
 
Is Retrospective Rating Right for You?


Publication
F250-006-000
 
Keys to Retro Success


Publication
F225-018-000
 
Letter of Intent for School Enrollment


Form
F242-382-000

World Language(s):
Español
 
Limited Liability Companies (LLC)


Publication
F214-021-000
 
Making the Best Treatment Choice for Your Chronic Low-back Pain


Publication
F252-081-000
 
Master Level Counselor Provider Account Application for Crime Victims


Form
F800-053-000
 
Medical Payment Guidance


Publication
F248-366-000
 
On-the-Job Training


Publication
F200-021-000
 
Opción 2: Lo que Usted Necesita Saber


Publication
F280-036-999

World Language(s):
Inglés
 
Pension Bond Rider


Form
F207-120-000
 
Plan Development: What Are My Rights & Responsibilities?


Publication
F280-018-000

World Language(s):
Español
 
Pocket Guide to Worker Rights


Publication
F101-165-000

World Language(s):
English/Español
 
Preferred Worker Employers Job Decsription


Form
F280-022-000
 
Preferred Worker Program


Publication
F280-021-000

World Language(s):
Español
 
Provider Network Agreement


Form
F245-397-000
 
Record Keeping


Publication
F214-011-000
 
Retrospective Rating Enrollment Decisions


Publication
F225-017-000
 
Self-Insurance Electronic Data Reporting System (SIEDRS) Enrollment Form


Form
F207-193-000
 
Self-Insurance Vocational Services Closing Cover Sheet


Form
F207-171-000
 
Self-Insurer's Bond - Existing Liabilities


Form
F207-068-000
 
SIF-4 Self Insured Employer's Request for Denial of Claim


Form
F207-163-000
 
Special Escrow Account - Amendment Agreement


Form
F207-137-000
 
Special Escrow Agreement


Form
F207-039-000
 
Standard Exception Classification


Publication
F214-016-000
 
Stay at Work Exam Room Card


Publication
F243-009-000
 
Stop illegal contracting: See it? Report it.


Publication
F625-114-000

World Language(s):
Español
 
Surety Rider


Form
F207-134-000
 
The ABCs of Classifications in Washington


Publication
F213-022-000
 
Verification of School Enrollment


Form
F242-055-000

World Language(s):
Español
 
What Are Your Rights as a Worker? (English/Cambodian)


Publication
F101-061-606

World Language(s):
English/한국의
English/русский
English/Español
English/Vi?t
 
What Are Your Rights as a Worker? (English/Korean)


Publication
F101-061-707

World Language(s):
English/កម្ពុជា
English/русский
English/Español
English/Vi?t
 
What Are Your Rights as a Worker? (English/Russian)


Publication
F101-061-404

World Language(s):
English/កម្ពុជា
English/한국의
English/Español
English/Vi?t
 
What Are Your Rights as a Worker? (English/Vietnamese)


Publication
F101-061-505

World Language(s):
English/កម្ពុជា
English/한국의
English/русский
English/Español
 
When a Loved One Dies at Work


Publication
F417-240-000

World Language(s):
Español
 
Workers' Comp Fraud Hurts YOU


Publication
F262-279-000
 
Your Independent Medical Exam (IME): Crime Victims Compensation Program


Publication
F800-115-000
 
Your Independent Medical Exam: For Employees of Self-Insured Businesses


Publication
F207-202-000

World Language(s):
Español
 
Your Premium Dollars at Work (2015)


Publication
F200-025-000
 





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