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Results for: Claims and Insurance - Self-Insurance
Title Number / Language
3 Things to Know about L&I's Medical Provider Network  F242-406-000 (English)
 F242-406-999 (Spanish)
A Guide to Workers' Compensation Benefits For Employees of Self-Insured Businesses  F207-085-000 (English)
 F207-085-999 (Spanish)
Acknowledgement of Security Interest  F207-143-000 (English)
Agreement of Assumption and Guarantee of Workers' Compensation Liabilities (Certified Self-Insurer)  F207-040-001 (English)
Agreement of Assumption and Guarantee of Workers' Compensation Liabilities - Application of Certification  F207-040-000 (English)
Amendment of Irrevocable Standby Letter of Credit  F207-112-111 (English)
Annual Supplemental Surety Information  F207-125-000 (English)
Application for Elective Coverage - Sole Proprietor, Partners, For-Profit Corporate Officers, or Member/Managers of Limited Liability Company (LLC)  F213-042-000 (English)
Application for Elective Coverage of Excluded Employments  F213-112-000 (English)
Application for Self-Insurance Certification  F207-001-000 (English)
Assessing Your Ability to Work: Your Rights and Responsibilities  F280-017-999 (Spanish)
 F280-017-000 (English)
Assignment of Account Agreement  F207-058-000 (English)
Cancellation of Elective Coverage - Sole Proprietors/Partner, Member of Limited Liability Company (LLC), Member of Limited Liability Partnership (LLP) or For-Profit Corporate Officers  F213-004-000 (English)
Cancellation of Elective Coverage for Excluded Employments  F213-005-000 (English)
Carrying Out Your Vocational Plan: Your Rights and Responsibilities During Plan Implementation  F280-019-000 (English)
Development of the plan: What are my rights and responsibilities? Vocational Rehabilitation Services  F280-018-999 (Spanish)
Employers' Guide to Self-Insurance in Washington State  F207-079-000 (English)
Help for Injured Workers of Self-Insured Employers  F207-213-000 (English)
 F207-213-999 (Spanish)
Irrevocable Standby Letter of Credit  F207-112-000 (English)
Memorandum of Understanding  F207-129-000 (English)
Memorandum of Understanding Irrevocable Standby Letter of Credit  F207-113-000 (English)
Notice to Employees - If a Job Injury Occurs  F207-037-909 (English/Spanish)
Overpayment Reimbursement Fund Request Coversheet  F207-212-000 (English)
Pension Bond Rider  F207-120-000 (English)
Plan Development: What Are My Rights & Responsibilities?  F280-018-000 (English)
Plan Room and Board Cost Encumbrance  F245-372-000 (English)
Preparing for Your Self-Insurance Audit  F207-110-000 (English)
Provider's Initial Report (PIR)  F207-028-000 (English)
Quarterly Report for Self-Insured Business  F207-006-000 (English)
Quarterly Statement of Supplemental Benefits Paid for Self-Insured Employers  F207-011-000 (English)
Request for Claim Information  F101-010-111 (English)
Schedule of Future Payments for the Balance of the Permanent Partial Disability Award  F207-162-000 (English)
Self Insurance Continuing Education Report of Course Completion  F207-191-000 (English)
Self Insurance Continuing Education Sponsor/Instructor Application for Course Approval  F207-192-000 (English)
Self-Insurance Certification Questionnaire  F207-176-000 (English)
Self-Insurance Continuing Education Application for Course Approval and Attendance  F207-206-000 (English)
Self-Insurance Electronic Data Reporting System (SIEDRS) Enrollment Form  F207-193-000 (English)
Self-Insurance Electronic Data Reporting System (SIEDRS): Enrollment Package 2.0  F207-194-000 (English)
Self-Insurance Medical Provider Billing Dispute Form  F207-207-000 (English)
Self-Insurance Report of Occupational Injury or Disease (SIF-5)  F207-005-000 (English)
Self-Insurance Vocational Reporting Form  F207-190-000 (English)
Self-Insurance Vocational Services Closing Cover Sheet  F207-171-000 (English)
Self-Insured Employer Certificate of Excess Insurance  F207-095-000 (English)
Self-Insured Employers' Medical Only Claim Closure Order and Notice  F207-020-111 (English)
 F207-020-999 (Spanish)
Self-Insured Employers' Permanent Partial Disability Closure Order and Notice - PPD-NTL  F207-164-999 (Spanish)
 F207-165-999 (Spanish)
 F207-165-000 (English)
Self-Insured Employers' Permanent Partial Disability Closure Order and Notice - PPD-TL  F207-164-000 (English)
Self-Insured Employers' Time Loss Claim Closure Order and Notice  F207-070-999 (Spanish)
 F207-070-000 (English)
Self-Insurer Accident Report (SIF-2)  F207-002-000 (English)
Self-Insurer's Bond - Existing Liabilities  F207-068-000 (English)
Self-Insurer's Pension Bond  F207-065-000 (English)
SIEDRS (Self-Insurance Electronic Data Reporting System) Data Change Request  F207-197-000 (English)
SIF-4 Self Insured Employer's Request for Denial of Claim  F207-163-000 (English)
SIF-5A Cover Sheet: Wage Calculations  F207-156-000 (English)
Special Escrow Account - Amendment Agreement  F207-137-000 (English)
Special Escrow Agreement  F207-039-000 (English)
Surety Rider  F207-134-000 (English)
Time Encumbrance Form  F245-376-000 (English)
Training Plan Cost Encumbrance  F245-374-000 (English)
Transfer of Attending Provider Form for Self Insured Workers  F207-114-000 (English)
 F207-114-999 (Spanish)
Transportation Cost Encumbrance  F245-375-000 (English)
Workers' Compensation Filing Information  F207-155-000 (English)
 F207-155-999 (Spanish)
Your Independent Medical Exam: For Employees of Self-Insured Businesses  F207-202-000 (English)
 F207-202-999 (Spanish)





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