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Results for: Claims and Insurance - Self-Insurance
Title:

Type:

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
 
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
 
Annual Supplemental Surety Information


Form
F207-125-000
 
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 Self-Insurance Certification


Form
F207-001-000
 
Cancellation of Elective Coverage - Sole Proprietors/Partner, Member of Limited Liability Company (LLC), Member of Limited Liability Partnership (LLP) or For-Profit Corporate Officers


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


Form
F213-005-000
 
Employers' Guide to Self-Insurance in Washington State


Publication
F207-079-000
 
Irrevocable Standby Letter of Credit


Form
F207-112-000
 
Memorandum of Understanding Irrevocable Standby Letter of Credit


Form
F207-113-000
 
Memorandum of Understanding


Form
F207-129-000
 
Overpayment Reimbursement Fund Request Coversheet


Form
F207-212-000
 
Plan Room and Board Cost Encumbrance


Form
F245-372-000
 
Preparing for Your Self-Insurance Audit


Publication
F207-110-000
 
Provider's Initial Report (PIR)


Form
F207-028-000
 
Quarterly Report for Self-Insured Business


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


Form
F207-011-000
 
Request for Claim Information


Form
F101-010-111
 
Schedule of Future Payments for the Balance of the Permanent Partial Disability Award


Form
F207-162-000
 
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
 
SIEDRS (Self-Insurance Electronic Data Reporting System) Data Change Request


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


Form
F207-156-000
 
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
 
Transportation Cost Encumbrance


Form
F245-375-000
 
Workers' Compensation Filing Information


Form
F207-155-000

World Language(s):
Español
 
Acknowledgement of Security Interest


Form
F207-143-000
 
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
 
Ayuda para trabajadores lesionados de empresas autoaseguradas


Publication
F207-213-999

World Language(s):
Inglés
 
Carrying Out Your Vocational Plan: Your Rights and Responsibilities During Plan Implementation


Publication
F280-019-000

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


Form
F207-155-999

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


Publication
F280-018-999

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


Publication
F280-017-999

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


Form
F207-114-999

World Language(s):
Inglés
 
Guía de beneficios de Compensación para los Trabajadores: para los empleados de empresas autoaseguradas


Publication
F207-085-999

World Language(s):
Inglés
 
Help for Injured Workers of Self-Insured Employers


Publication
F207-213-000

World Language(s):
Español
 
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 de tiempo perdido para empleadores autoasegurados


Form
F207-070-999

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


Form
F207-020-999

World Language(s):
Inglés
 
Pension Bond Rider


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


Publication
F280-018-000

World Language(s):
Español
 
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
 
Su examen médico independiente: para empleadores de negocios autoasegurados


Publication
F207-202-999

World Language(s):
Inglés
 
Surety Rider


Form
F207-134-000
 
Tres cosas que debe conocer sobre la Red de proveedores médicos de L&I


Publication
F242-406-999

World Language(s):
Inglés
 
Your Independent Medical Exam: For Employees of Self-Insured Businesses


Publication
F207-202-000

World Language(s):
Español
 





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