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Request for Preferred Workers Status

Used by vocational providers to apply for preferred worker status on behalf of an industrially injured worker.



Formulario
F280-023-000
 
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.



Formulario
F800-031-000

Otro(s) idioma(s):
Español
 
Application for Benefits - Crime Victims

This application is used by victims of crime in Washington State to apply for benefits such as compensation for time lost from work; loss of financial support; and medical or mental health treatment.

The application for Homicide Claims is available online by searching for form number F800-120-000.



Formulario
F800-042-000
 
Request for Survivor Counseling Benefits / Solicitud para beneficios de apoyo para los sobrevivientes (English/español)  

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

Utilizado por miembros de la familia inmediatos de víctimas de homicidio para solicitar asesoría de salud mental.



Formulario
F800-057-909
 
Crime Victims Provider's Request for Adjustment

Used by providers to request an adjustment to their bill if their entire bill was paid in error, or if a portion of the bill was overpaid or underpaid. Attach required reports and/or documentation to support the request.



Formulario
F800-064-000
 
Statewide Payee Registration and W-9 Form Crime Victims

Used by a provider assisting victims of crime to obtain a taxpayer ID number. Note: Register now for direct deposit available January 2013.



Formulario
F800-065-000
 
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.



Publicación
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.



Formulario
F800-076-000
 
Provider Change Form for Crime Victims Compensation

Providers use to inform L&I that they have changes to their account. Such as changes to their Tax ID address/name, business address, billing address, name, or termination of account. This also includes a W-9 form.



Formulario
F800-089-000
 
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.



Formulario
F207-020-111

Otro(s) idioma(s):
Español
 
Notificación de decisión de cierre para reclamos únicamente médicos para empleadores autoasegurados

Usada solamente por los empleadores autoasegurados o sus representantes, esta es una notificación legal para un trabajador lesionado indicando que su reclamo está cerrado con beneficios médicos solamente.  Esta orden se usa solamente cuando no se ha pagado compensación de tiempo perdido ni tampoco indemnización por discapacidad parcial permanente.



Formulario
F207-020-999

Otro(s) idioma(s):
Inglés
 
Notificación de decisión de cierre para reclamos de tiempo perdido para empleadores autoasegurados

Usada solamente por los empleadores autoasegurados o sus representantes, esta es una notificación legal para un trabajador lesionado indicando que su reclamo está cerrado.  Esta orden se usa solamente cuando se ha pagado compensación de tiempo perdido pero no se está pagando una indemnización por discapacidad parcial permanente.



Formulario
F207-070-999

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

Usada solamente por los empleadores autoasegurados o sus representantes.  Esta es una notificación legal para un trabajador lesionado indicando que su reclamo está cerrado.  Esta orden se usa solamente cuando se ha pagado compensación de tiempo perdido y también se está pagando una indemnización por discapacidad parcial permanente.



Formulario
F207-164-999

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

Usada solamente por los empleadores autoasegurados o sus representantes, esta es una notificación legal para un trabajador lesionado indicando que su reclamo está cerrado.  Esta orden se usa solamente cuando no se ha pagado compensación de tiempo perdido pero se está pagando una indemnización por discapacidad parcial permanente.



Formulario
F207-165-999

Otro(s) idioma(s):
Inglés
 
Independent Medical Exam Comments
Used by the injured worker to provide comments to L&I about their recent medical exam by an IME.

Formulario
F245-053-000

Otro(s) idioma(s):
Español
 
Comentarios Sobre el Exámen Médico Independente

Usado por el trabajador lesionado para proporcionarle comentarios a L&I sobre su examen médico reciente de un Examen Médico Independiente (IME, por su sigla en inglés).



Formulario
F245-053-999

Otro(s) idioma(s):
Inglés
 
Quarterly Reporting for Drywall

Used by drywall employers as a guide to completing quarterly and supplemental reports. This includes filled out samples of F212-050-000 and F212-051-000.



Formulario
F212-224-000

Otro(s) idioma(s):
Español
 
Employment History Form

Used to provide your employment history for the past three years, including self-employment and volunteer work.

Please start with your most recent job and work backwards. Please list any gaps or interruptions in your work history.  If you were unemployed at any time, please explain why.  Did you apply for (or receive) unemployment benefits during the time period? If yes, what dates did you receive unemployment benefits?  Did you seek employment during the time period?  If no, why didn’t you seek employment?



Formulario
F242-109-000

Otro(s) idioma(s):
Español
 
Formulario de historial de empleo

Usado por el trabajador lesionado para reportar su historial de empleo y el salario de cada trabajo durante los últimos tres años



Formulario
F242-109-999

Otro(s) idioma(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.



Formulario
F800-049-000
 
Avoid Liability for Your Subcontractor's Unpaid Workers' Comp Premiums
Fact sheet: Tells construction contractors how to protect themselves from liability for their subcontractor's unpaid workers' compensation premiums.

Publicación
F262-262-000

Otro(s) idioma(s):
Español
 
Preparing for Your Self-Insurance Audit

Pamphlet/booklet: Helps self-insured employers understand and prepare for an audit.



Publicación
F207-110-000
 
The ABCs of Classifications in Washington
Book: Aids in understanding Washington State's workers' compensation classification system and how classifications are applied to different types of businesses.

Publicación
F213-022-000
 
Is Retrospective Rating Right for You?
Pamphlet: Provides information about L&I's Retrospective Rating Program. In Retro, employers can earn a partial refund of workers' compensation premiums if they reduce workplace injuries and lower associated claim costs.

Publicación
F250-006-000
 
Workers' Compensation Discrimination / Discriminación porque se lesionó en su trabajo (English/español)

Fact sheet: Explains workers' legal right to file a workplace injury claim and how to file a complaint if discrimination has occurred.

Hoja de información:  Explica el derecho legal de los trabajadores para presentar un reclamo de lesión en el lugar de trabajo y como presentar una queja si ocurre una discriminación.



Publicación
F262-249-909
 
Self-Insurance Certification Questionnaire

Used by employers applying to become self-insured to describe their proposed workers' compensation program.



Formulario
F207-176-000
 
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.



Formulario
F625-077-000
 
Reporte trimestral para la industria de tabla de yeso

Usado por los empleadores de tabla de yeso como una guía para completar los informes trimestrales y suplementarios.  Esto incluye ejemplos para completar el formulario Número F212-050-000 y el F212-051-000.



Formulario
F212-224-999

Otro(s) idioma(s):
Inglés
 
SIF-4 Self Insured Employer's Request for Denial of Claim
Used by self-insured employers or their representatives to notify an injured worker that the employer or representative is requesting that L&I deny their claim.

Formulario
F207-163-000
 
Performance Based Physical Capacities Evaluation

Used by occupational and physical therapy providers as an optional reporting format for a Performance-based Physical Capacities Evaluation.



Formulario
F245-023-000
 
Assessment Closing Report

Used by only private sector vocational rehabilitation providers to document vocational assessment to determine if a worker is employable based upon transferable skills.



Formulario
F252-029-000
 
Department of Labor and Industries Home Modification Acknowledgement of Responsibilities

Used by both workers and bidding contractors to read, sign and submit to L&I to verify that they have read, understand and accept their respective responsibilities in the home modification process.



Formulario
F247-003-000

Otro(s) idioma(s):
Español
 
Sports Teams and Youth Workers

Fact sheet: Explains the requirements for sports organizations that engage young people as volunteers or employees to referee, assist or work for the organizations. The focus is workers' compensation coverage and minor work rules.



Publicación
F700-130-000
 
Letter of Intent for School Enrollment
Use by a full-time student who is entitled to receive pension benefits. The student must be at least 18 years old and no older than 23 years old. This form is to prove the students intention to register in an accredited school during the next quarter/semester.

Formulario
F242-382-000

Otro(s) idioma(s):
Español
 
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.



Formulario
F800-098-000
 
Massage Therapy Treatment Authorization Fax Request

Used by a licensed massage practitioner/clinic to request authorization for outpatient massage therapy services for L&I claims.



Formulario
F248-357-000
 
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
 
Notice of Occupational Disease or Infection

Used by medical providers to notify L&I that an occupational disease or infection has been diagnosed and that the worker has been advised that their condition may be work-related. This form can be used if the worker does not complete a Report of Accident or Occupational Disease (ROA) but should not be completed in place of an ROA.



Formulario
F242-243-000
 
Self-Insurance Vocational Reporting Form

Used by self-insured employers and their representatives to report to L&I an injured worker's eligibility for vocational services or ability to work. This replaces F207-121-000 Employability Assessment Report (EAR).



Formulario
F207-190-000
 
Housing and Board Cost Encumbrance
To record the costs for housing and board. For use only with plans approved after 1/1/2008.

Formulario
F245-372-000
 
Training Plan Cost Encumbrance

To record the training costs. For use only with plans approved after 1/1/2008.



Formulario
F245-374-000
 
Transportation Cost Encumbrance

To record the costs for transportation. For use only with plans approved after 1/1/2008.



Formulario
F245-375-000
 
Plan Time Encumbrance
To record the work plan time. For use only with plans approved after 1/1/2008.

Formulario
F245-376-000
 
Plan Development Quality Assurance Review Form

For use internally by L&I Vocational Service Specialists (VSSs) to determine if all required components are included in the submitted plan. Can be used by VRCs as a tool. DO NOT SUBMIT TO L&I.



Formulario
F280-007-000
 
Assessment Eligible Quality Assurance Review Form

For use internally by L&I Vocational Service Specialists (VSSs) to determine if all required components are included in the submitted assessment.  Can be used by VRCs as a tool.  DO NOT SUBMIT TO L&I.



Formulario
F280-008-000
 
Plan Development Recommending Plan Approval Routing Sheet
Routing slip that accompanies the Vocational Services Closing Cover Sheet (F252-028-000) which is used to close vocational services to an injured worker only if you are recommending Plan Approval. For all other closing reports, use Vocational Closing Report Routing Sheet (F252-027-000).

Formulario
F280-013-000
 
Address Change Request for Injured Workers
Completed and signed by a State Fund injured worker to notify L&I of a change in address. All address changes must be submitted in writing and signed by the injured worker.

Formulario
F242-388-000

Otro(s) idioma(s):
Español
 
Solicitud para cambio de dirección para trabajadores lesionados

Para ser completada y firmada por un trabajador lesionado del Fondo estatal para notificarle a L&I de un cambio de dirección.  Todos lo cambios de dirección deben someterse por escrito y estar firmados por el trabajador lesionado.



Formulario
F242-388-999

Otro(s) idioma(s):
Inglés
 
Self Insurance Continuing Education Sponsor/Instructor Application for Course Approval

Used by sponsors or instructors of continuing education courses, when requesting the department assign credit to a course so that department-approved claims administrators who attend can earn credit toward recertification under the Self Insurance Continuing Education program.



Formulario
F207-192-000
 
Self Insurance Continuing Education Report of Course Completion

Used by department-approved claims administrators to report course completion for obtaining continuing education credit.



Formulario
F207-191-000
 
Self-Insurance Electronic Data Reporting System (SIEDRS) Enrollment Form
Used by self-insured employers and third party administrators to enroll for participation in the Self Insurance Electronic Data Reporting System (SIEDRS). F207-197-000 is SIEDRS (Self-Insurance Electronic Data Reporting System) Data Change Request.

Formulario
F207-193-000
 
Application for Pension Benefits by Spouse or Children

Used by a spouse or dependent that was chosen by the deceased worker to receive a survivor benefit. At the time the worker was determined to be totally permanently disabled he/she made a decision to leave a survivor benefit to a spouse or dependent if the worker dies.



Formulario
F242-391-000

Otro(s) idioma(s):
Español
 
Solicitud para beneficios de pensión presentado por el cónyuge o los hijos

Formulario:  Usado por el cónyuge o dependiente elegido por el trabajador fallecido para recibir un beneficio de sobreviviente.  En el momento en que se determinó que el trabajador estaba permanentemenre y totalmente discapacitado el/ella tomó la decisión de dejar el beneficio de sobreviente al cónyuge o dependiente si el trabajador fallecía.



Formulario
F242-391-999

Otro(s) idioma(s):
Inglés
 
Your Rights as a Worker in Washington State/ Sus derechos como trabajador en el estado de Washington (English/español)

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.

Cartel requerido: Da un resumen de los derechos de los trabajadores bajo las leyes de salario y horas de Washington.  Los temas incluyen el salario mínimo, horas extras, comida y períodos de descanso, deducciones y empleo de adolescentes menores de 18 años de edad.  También cubre las disposiciones de ausencia familiar bajo la ley federal y estatal y la ausencia para los cónyuges del personal militar y las víctimas de violencia doméstica.  Aviso:  Los empleadores tanto en la industria de la agricultura y otros sectores en el estado de Washington deben colocar este cartel donde los trabajadores puedan verlo.

Por favor solicítelo de L&I o imprímalo en papel de tamaño 11x17 pulgadas.

Obtenga consejos para imprimir carteles. 

 

 

 



Cartel
F700-074-909
 
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.

Publicación
F800-102-000
 
Self-Insurance Electronic Data Reporting System (SIEDRS): Enrollment Package 2.0

Book: Explains the technical requirements for participating in SIEDRS, the Self-Insurance Electronic Data Reporting System.



Publicación
F207-194-000
 
What You Need to Know if You Don't Get Paid: A Worker's Guide to the Washington State Wage Payment Act / 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 (English/español)

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.

Hoja de información:  Hace un resumen de los derechos y responsabilidades de los trabajadores referentes al salario mínimo, pago, horas trabajadas y horas extras y explica cómo presentar una queja de salario, incluye respuestas a varias preguntas frecuentes.



Publicación
F700-153-909
 
Pension Benefits Questionnaire

Used by an injured worker who receives an order that states he or she is totally permanently disabled. This questionnaire must be completed in full and all necessary documents attached before his or her pension benefit options can be calculated.



Formulario
F242-393-000

Otro(s) idioma(s):
Español
 
Instrucciones para el registro de una queja sobre salario prevaleciente

Pídale a L&I que haga una investigación de un asunto relacionado con el salario prevaleciente que afecte a uno o más empleados.



Formulario
F700-146-999

Otro(s) idioma(s):
Inglés
 





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