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Results for: Claims and Insurance - Claims
Title Number / Language
Declaration of Entitlement - Disabled Child or Guardian Benefits  F242-421-000 (English)
 F242-421-999 (Spanish)
Declaration of Entitlement - Surviving Spouse/Registered Domestic Partner  F242-420-000 (English)
 F242-420-999 (Spanish)
Declaration of Entitlement for Dependent of Deceased Worker Benefits Under Industrial Insurance  F242-422-000 (English)
 F242-422-999 (Spanish)
Declaration of Entitlement for Totally Disabled Worker Benefits Under Industrial Insurance  F242-423-000 (English)
 F242-423-999 (Spanish)
Employer's Job Description  F252-040-000 (English)
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)
Activity Prescription Form (APF)  F242-385-000 (English)
Address Change Request for Injured Workers  F242-388-000 (English)
 F242-388-999 (Spanish)
Address Change Request for Pensioners  F242-107-000 (English)
 F242-107-999 (Spanish)
Affidavit for Time Loss Compensation Benefits  F242-395-000 (English)
 F242-395-999 (Spanish)
Amendment of Irrevocable Standby Letter of Credit  F207-112-111 (English)
Application for Loss of Earning Power Compensation Medical  F242-208-909 (English/Spanish)
 F242-208-999 (Spanish)
Application for Loss of Earning Power Vocational  F242-209-909 (English/Spanish)
 F242-209-999 (Spanish)
Application for Pension Benefits by Spouse or Children  F242-391-000 (English)
Application for Structured Settlement  F240-002-000 (English)
 F240-002-999 (Spanish)
Application for Loss of Earning Power (LEP) - Compensation Medical  F242-208-000 (English)
Application to Reopen Claim Due to Worsening Condition  F242-079-000 (English)
Application to Reopen Claim due to Worsening Condition  F242-079-999 (Spanish)
Application for Loss of Earning Power (LEP) - Vocational  F242-209-000 (English)
Are You an Employer Who Can Provide On-the-Job Training?  F280-033-000 (English)
Assessing Your Ability to Work: Your Rights and Responsibilities  F280-017-000 (English)
 F280-017-999 (Spanish)
Authorization to Release Claim Information  F101-010-000 (English)
Authorization to Release Information  F262-005-000 (English)
 F262-005-999 ()
Buprenorphine Transdermal Patch Authorization Request Form  F252-110-000 (English)
Carrying Out Your Vocational Plan: Your Rights and Responsibilities During Plan Implementation  F280-019-000 (English)
Chemical Exposure Questionnaire Packet  F242-409-000 (English)
 F242-409-999 (Spanish)
Chronic Opioid Request Form  F252-091-000 (English)
Claim for Pension By Dependents  F242-062-000 (English)
 F242-062-999 (Spanish)
Claim for Pension by Spouse or Children  F242-056-000 (English)
 F242-056-999 (Spanish)
Claim Suppression Complaint  F262-024-000 (English)
 F262-024-999 (Spanish)
CMS 1500  F245-127-000 (English)
Common Errors on the Interpretive Services Appointment Record (ISAR)  F245-436-000 (English)
Department of Labor and Industries Home Modification Acknowledgement of Responsibilities  F247-003-000 (English)
 F247-003-999 ()
Development of the plan: What are my rights and responsibilities? Vocational Rehabilitation Services  F280-018-999 (Spanish)
Direct Entry Billing Manual  F245-437-000 (English)
Doctor's Worksheet for Rating Dorso-Lumbar & Lumbo-Sacral Impairment  F252-006-000 (English)
Employee Misconduct: Information for Employers  F417-254-000 (English)
Employers' Guide to Workers' Compensation Insurance in Washington State  F101-002-000 (English)
 F101-002-999 (Spanish)
Employment History Form  F242-109-000 (English)
 F242-109-999 (Spanish)
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.)  F245-392-000 (English)
FileFast postcard handout for workers  F242-398-000 (English)
FileFast poster for workers  F242-399-000 (English)
FileFast wallet card for workers  F242-400-000 (English)
Frequently Asked Questions about Job Modifications  F245-057-000 (English)
Functional Capacity Summary  F245-434-000 (English)
Functional Recovery Interventions Tracking Sheet  F245-420-000 (English)
Getting Back to Work: It's Your Job and Your Future  F200-001-000 (English)
 F200-001-999 (Spanish)
Getting up-to-speed on regulations for Washington businesses?  F101-174-000 (English)
Have you been injured at work?  F242-404-999 (Spanish)
Hearing Aid Replacement Form  F242-414-000 (English)
Hearing Services Worker Information  F245-049-000 (English)
Home Modification for Workers with Catastrophic Injuries  F252-060-000 (English)
 F252-060-999 (Spanish)
Home Modification for Workers with Catastrophic Injuries - Questions and Answers for Contractors  F252-061-000 (English)
 F252-061-999 (Spanish)
How Social Security Benefits May Reduce Your Workers' Compensation Payments  F242-427-000 (English)
How to Protest a Department of Labor and Industries Decision  F242-363-909 (English/Spanish)
Independent Contractor Guide: A Step-by-Step Guide to Hiring Independent Contractors in Washington State  F101-063-999 (Spanish)
Independent Contractor or Covered Worker? - Your rights to workers' compensation, minimum wage and overtime  F212-250-000 (English)
 F212-250-999 (Spanish)
Injured by a third party?  F249-008-000 (English)
Injured Workers: Leaving Washington, But Still Need Treatment  F242-412-909 (English/Spanish)
International Travel for Work  F242-419-000 (English)
Interpreter Services for Injured Workers and Crime Victims  F245-412-000 (English)
Interpretive Services Appointment Record (ISAR)  F245-056-000 (English)
Irrevocable Standby Letter of Credit  F207-112-000 (English)
Job Modification Assistance Application  F245-346-000 (English)
L&I Benefits for Workers Who Are Terminally Ill  F252-094-000 (English)
Legal Representation Notification  F242-425-000 (English)
 F242-425-999 (Spanish)
Legal Representative Payment Method Authorization Form  F120-212-000 (English)
Massage Therapist: Independent Contractor or Covered Worker?  F212-248-000 (English)
Medical Device Review Request  F252-013-000 (English)
Medical Payment Guidance  F248-366-000 (English)
Memorandum of Understanding  F207-129-000 (English)
Memorandum of Understanding Irrevocable Standby Letter of Credit  F207-113-000 (English)
Notice of Occupational Disease or Infection  F242-243-000 (English)
Notice to Employees -- If a Job Injury Occurs  F242-191-909 (English/Spanish)
Occupational Disease & Employment History  F242-071-000 (English)
 F242-071-911 (Spanish)
 F242-071-999 (Spanish)
Occupational Disease Employment History Hearing Loss  F262-013-000 (English)
 F262-013-999 (Spanish)
Occupational Disease Work History - Continuation  F242-071-111 (English)
Occupational Hearing Loss Questionnaire  F262-016-000 (English)
 F262-016-999 (Spanish)
On-the-Job Training  F200-021-000 (English)
Opioid Treatment Agreement  F252-095-000 (English)
 F252-095-999 (Spanish)
Payment Method Authorization  F120-211-000 (English)
 F120-211-999 (Spanish)
Pension Benefits Questionnaire  F242-393-000 (English)
Plan Development: What Are My Rights & Responsibilities?  F280-018-000 (English)
Pocket Guide to Worker Rights  F101-165-000 (English)
 F101-165-909 (English/Spanish)
Pre-Job Accommodation Assistance Application  F245-350-000 (English)
Preferred Worker Program  F280-021-000 (English)
 F280-021-999 (Spanish)
Provider's Request for Adjustment  F245-183-000 (English)
PT/OT Referral Form  F252-099-000 (English)
Report of Accident (ROA) Workplace Injury, Accident or Occupational Disease  F242-130-000 (English)
Request for Claim Information  F101-010-111 (English)
 F101-010-999 (Spanish)
Resume Cover Sheet  F242-418-000 (English)
Self-Insurance Option 2 Vocational Services Summary Form  F280-064-000 (English)
Self-Insurance Report of Occupational Injury or Disease (SIF-5)  F207-005-000 (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)
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  F207-070-000 (English)
 F207-070-999 (Spanish)
Self-Insurer Accident Report (SIF-2)  F207-002-000 (English)
Self-Insurer's Pension Bond  F207-065-000 (English)
Settling your injured worker's L&I claim: A new option for injured workers 50 and older  F240-004-000 (English)
Settling your L&I claim might be right for you: An option for injured workers 50 or older  F240-003-000 (English)
 F240-003-999 (Spanish)
SIF-5A Cover Sheet: Wage Calculations  F207-156-000 (English)
State Fund Option 2 Vocational Services Summary Form  F280-063-000 (English)
Statement for Miscellaneous Services  F245-072-999 (Spanish)
Statement for Pharmacy Services  F245-100-000 (English)
Statement for Retraining and Job Modification Services  F245-030-000 (English)
Stay at Work Exam Room Card  F243-009-000 (English)
Stay at Work Expense Reimbursement Application for Employers Tools, Clothing, Training.  F243-003-000 (English)
Stay at Work Wage Reimbursement Application for Employers  F243-001-000 (English)
Structured Settlement Income and Expense Worksheet  F240-007-000 (English)
Subacute Opioid Request Form  F252-097-000 (English)
Submission of Provider Credentials for Interpretive Services  F245-055-000 (English)
Termination of Agreement (Rescission)  F245-050-000 (English)
Transfer of Care Card  F245-037-000 (English)
 F245-037-999 (Spanish)
Travel Reimbursement Request  F245-145-000 (English)
 F245-145-999 (Spanish)
Understanding Your Functional Capacity Evaluation  F245-416-000 (English)
 F245-416-999 (Spanish)
Verification of School Enrollment  F242-055-000 (English)
Vocational Training Plan Ownership Agreement for Tools and Equipment  F245-351-000 (English)
 F245-351-999 (Spanish)
Work Status Form (formerly Worker Verification Form)  F242-052-000 (English)
 F242-052-999 (Spanish)
Worker Request for Union Dispatch Records  F242-410-000 (English)
 F242-410-999 (Spanish)
Workers' Compensation Benefits: A Guide for Injured Workers  F242-104-000 (English)
 F242-104-999 (Spanish)
Workers' Compensation Coverage for Wineries  F212-249-000 (English)
Workers' Compensation Filing Information  F207-155-000 (English)
 F207-155-999 (Spanish)
Workers' Compensation Requirements for the Marijuana Industry  F242-415-000 (English)
Workers: Activity coaching can help you get back to doing what you love  F280-061-000 (English)
 F280-061-999 (Spanish)
Your Independent Medical Exam  F245-224-000 (English)
 F245-224-999 (Spanish)
Your Premium Dollars at Work (2014)  F200-023-000 (English)
Your Premium Dollars at Work (2015)  F200-025-000 (English)
Your Premium Dollars at Work (2016)  F200-027-000 (English)

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