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Application for Certificate of Competency as an Inspector of Pressure Retaining Items
To apply for a certificate of competency as an Inspector of Pressure Retaining items. You can only mail or fax this form to L&I. Emailed forms are not accepted. NOTE: Applications MUST be received no later than 30 days prior to the exam date. Incomplete applications WILL NOT be accepted.

Formulario
F620-040-000
 
Boiler/Pressure Vessel Clearance Variance Request
To request a clearance variance on a boiler or pressure vessel. You can only mail or fax this form to L&I. E-mailed forms are not accepted.

Formulario
F620-041-000
 
Rental Boiler Operating Permit - Good at this Location Only
To request a permit to use a rental boiler at one location only.

Formulario
F620-042-000
 
Historical Boilers Inspection Guideline
Inspection sheet for boiler inspectors. 4 pages.

Formulario
F620-043-000
 
Incident Report Boiler or Pressure Vessel
Used for the reporting of incident with boilers or a pressure vessels.

Formulario
F620-044-000
 
Elevator Installation Variance Application

Property owner or elevator company can apply for a variance to install an elevator. 4 pages.



Formulario
F621-048-000
 
Elevator Information Update

This form is required by L&I before they can process any changes to the ownership, physical or mailing address.



Formulario
F621-050-000
 
Elevator Five-Year Safety Test Report

This report is used by L&I for its five-year safety inspection of an elevator.



Formulario
F621-051-000
 
Hydraulic Overpressure Test

To be submitted when a valve is changed or a seal is broken.



Formulario
F621-052-000
 
Extension Request

This form is to request a time extension from an unforeseen circumstances for overdue corrections for conveyances.



Formulario
F621-053-000
 
Test of Escalator Safety Devices

A licensed elevator mechanic shall perform this test once a year and mail a copy to L&I.



Formulario
F621-055-000
 
Conveyance Installation Approval by Building Official

Used by the installer to notify L&I that a conveyance is proposed for installation in a buildiing.



Formulario
F621-056-000
 
New Elevator Installation Checklist

Checklist for the elevator company/contractor to complete before the call L&I for an elevator inspection. Includes DEc 2010 letter on ASME checklists.



Formulario
F621-057-000
 
Owner Requested Red Tag Form

Used by the owner for red tagging a unit that is to be placed or to remain out of service.



Formulario
F621-063-000
 
Request for Duplicate Elevator Certificate

Used to request a duplicate elevator license or a duplicate operating permit for a conveyance.



Formulario
F621-065-000
 
Application for Licensure as an Elevator Mechanic

This is an application for certification as an Elevator Mechanic and is NOT a license to perform work. A contractor's license is still required by L&I.



Formulario
F621-067-000
 
Temporary Licensed Elevator Mechanic

This temporary license is limited to the mechanical and electrical operation, construction, installation, alteration, maintenance, inspection, relocation and repair of conveyances.



Formulario
F621-068-000
 
Licensed Elevator Contractor (LC) Operation

Contractors who install, construct, repair, alter or maintain elevators need to be licensed by the Elevator Program through L&I and with L&I's contractor registration program.



Formulario
F621-069-000
 
License Requirements for Elevator Mechanics and Contractors
Fact sheet: Explains licensing and testing requirements for mechanics who work on elevators and for contractors who install, repair or maintain elevators.

Publicaci贸n
F621-070-000
 
Elevator Continuing Education Course Application

This is used to apply for approval of elevator related continuing education courses.



Formulario
F621-077-000
 
Elevator Continuing Education Instructor Application

Application to become an instructor for elevator related courses.



Formulario
F621-078-000
 
Plan Approval Request - Recreational Vehicles and Recreational Park Trailers

Plans to build recreational vehicles or park trailers need approval from L&I. This form is used as part of the approval process.



Formulario
F622-006-000
 
Alteration Fire Safety Pre-Inspection Checklist

Checklist for homeowners on how to upgrade their pre-HUD homes to approach the HUD standards in the area of fire safety.



Formulario
F622-011-000

Otro(s) idioma(s):
Espa帽ol
 
Alteration Fire Safety Pre-Inspection Checklist -Spanish Lista de Comprobación para la Preinspección de Seguridad contra Incendios

Checklist for homeowners on how to upgrade their pre-HUD homes to approach the HUD standards in the area of fire safety.



Formulario
F622-011-999

Otro(s) idioma(s):
Ingl茅s
 
Electric / Gas Conversion Pre-Inspection Checklist

This checklist is generic in content and may not include all requirements for your particular installation. The manufacturer's installation instruction must be adhered to and available to the inspector at the time of the inspection.



Formulario
F622-013-000
 
Air Conditioner/Heat Pump Pre-Inspection Checklist

This checklist is designed to be generic in content and may not include all requirements for your particular installation.



Formulario
F622-014-000
 
Wood / Pellet Stove / Fireplace Pre-Inspection Checklist

This checklist is designed to be generic in content and may not include all requirements for your particular installation.



Formulario
F622-015-000
 
Application for State Plan Insignia for Recreational Vehicles and Recreational Park Trailers

To apply for an insignia for a recreational vehicle.



Formulario
F622-021-000
 
Insignia Continuation Sheet Recreational Vehicles and Park Trailers

Continuation sheet to apply for an insignia.



Formulario
F622-021-111
 
Plan Approval Request - Conversion Vendor / Medical Units

Used in requesting a plan approval for Conversion Vendor or Medical Unit factory-assembled structures.



Formulario
F622-035-000
 
Low Voltage Fire / Intrusion Alarm Checklist

This checklist is designed to be generic in content and may not include all requirements for your particular installation.



Formulario
F622-038-000
 
Alteration Re-Roofing for Low Slope Roofing

Checklist used by the contractor when altering a low slope roof.



Formulario
F622-039-000
 
Flood Damaged Manufactured Home Checklist

Checklist on how to repair a flood damaged manufactured home. After the contractor has done all that is required by the checklist they call L&I for an inspection.



Formulario
F622-040-000
 
Is it a Manufactured / Mobile Home?

If your home has any of the items in this document, it is a manufactured / mobile home and requires inspections for all alterations by L&I's Factory Assembled Structures Section.



Formulario
F622-043-000
 
Steel or Wrought-Iron Gas Line Pre-Inspection Checklist

This checklist is used by the contractor when installing steel or wrought-iron gas line. Be sure you can answer YES to all questions before calling L&I for an inspection.



Formulario
F622-044-000
 
Gas Room Heaters Pre-Inspection Checklist

This checklist is used by the contractor when installing gas room heaters. Be sure you can answer YES to all questions before calling L&I for an inspection.



Formulario
F622-045-000
 
Copper Tubing Gas Line Pre-Inspection Checklist

This checklist is used by the contractor when installing gas lines with copper tubing. Be sure you can answer YES to all questions before calling L&I for an inspection.



Formulario
F622-046-000
 
Gas Piping Test Affidavit

You fill out, print and make a copy of this form on your company's letterhead. This affidavit must be available for the L&I inspector when the inspection is made.



Formulario
F622-048-000
 
Your Manufactured / Mobile Home
Pamphlet/booklet: Covers things you should consider when altering your home. Defines what is meant by alteration, repair and replacement and includes tips for hiring a registered contractor. It also includes contact information for L&I Consumer Assistance Program for owners of new manufactured/mobile homes.

Publicaci贸n
F622-049-000

Otro(s) idioma(s):
Espa帽ol
 
Alteration Polybutylene Re-Pipe Pre-Inspection Checklist

This checklist is used by the contractor when altering a polybutylene re-pipe. Be sure you can answer YES to all questions before calling L&I for an inspection.



Formulario
F622-053-000
 
Homeowners Manufactured / Mobile Home Variance Request

This variance request applies only to the installations performed by a previous owner and does not apply to any home during the warranty period.



Formulario
F622-054-000
 
Decertification of Manufactured and Mobile Homes

This document shows the steps to decertify a manufactured or mobile home.



Formulario
F622-063-000
 
Plan Approval Request - Factory Built Structures and Commercial Coaches

A manufacturer of factory-built structures and/or commercial coaches uses this form to submit plans to L&I for review.



Formulario
F623-006-000
 
Notification to Local Enforcement Agency

L&I sends this form to notify the local agencies when a factory-built structure is being shipped within a county or city limits.



Formulario
F623-013-000
 
Application for Insignia for Factory Assembled Structures

Manufacturers uses this form to apply for an official insignia for a factory-built structure that has a plan approval number.



Formulario
F623-014-000
 
Application for Insignia for Commercial Coaches

Manufacturer uses this form to apply for an official insignia for commercial coaches that have a plan approval number.



Formulario
F623-019-000
 
Application for Insignia Conversion Vendor/Medical Units

Used to apply for an official insignia for conversion vendor or medical unit factory-assembled structures. See sample form for instructions about how to fill out the form correctly.



Formulario
F623-021-000
 
Application for Construction Contractor Registration

This is the form you would complete to register as a construction contractor.



Formulario
F625-001-000
 
Facts About Construction Liens
Fact sheet: Explains the basics of the construction lien law to help consumers protect themselves.

Publicaci贸n
F625-017-000
 
Waiver of Lien by Contractor, Subcontractor(s) and Supplier

This is a waiver of lien by a contractor or a subcontractor or supplier.



Formulario
F625-029-000
 
Safety Standards for Laundry Machinery and Operations WAC 296-303

Laundry Machinery and Operations applies to moving parts of equipment used in laundries and to conditions peculiar to this industry, with special reference to the point of operation of laundry machines in an establishment wherein the washing, ironing, or other finishing of clothes, or any other textiles is done.



Manual
F414-012-000
 
Model Disclosure Statement Notice to Customer

This disclosure statement is given to the consumer (customer) from the contractor showing they are registered in the state of Washington. The consumer (customer) signs this form as acknowledgement of receipt.



Formulario
F625-030-000
 
Safety Standards for Logging Operations WAC 296-54

This chapter establishes safety practices for all types of logging, log road construction and other forest activities using logging machinery and/or power saws regardless of the end use of the wood. This includes; logging, cutting and transporting timber, cutting timber, log harvesting logging, pulpwood logging camps, rails, rough wood, manufacturing, stump removing in the field, timber piling, timber pole cutting, tree chipping in the field, wood chipping in the field. In addition, logging and personal protective equipment, hand and portable powered tools, falling and bucking, tree pulling, mechanized falling, climbing equipment, rigging, spars, wire rope and various types of cable logging systems, guylines, tail/lift trees and anchors, yarding, skidding, landing, transportation of logs and stationary trailer loaders, log unloading, booms, and rafting grounds, transportation crews, signals and signal systems.



Manual
F414-016-000
 
Contractor Complaint Form

Used by a home owner to file a complaint against a contractor.



Formulario
F625-033-000
 
Construction Contractors: Get the Facts, Get Registered
Pamphlet/booklet: Explains the steps to register as a construction contractor in Washington State.

Publicaci贸n
F625-040-000

Otro(s) idioma(s):
Espa帽ol
 
Safety Standards for Shipbuilding, Ship Repairing and Shipbreaking Chapter 296-304 WAC

Safety Standards for Shipbuilding, Ship Repairing and Shipbreaking Chapter 296-304 WAC



Manual
F414-025-000
 
Subscription Request for Construction Contractor and Electrical Basic - CD

This form is to be used to purchase the CD ROM of registered construction contractors, registered electrical contractors, plumbers and electricians.



Formulario
F625-051-000
 
Chapter 296-45 WAC - Safety Standards for Electrical Workers

Safety Standards for Electrical Workers, 296-45 WAC, consist of the requirements for safeguarding employees against electrical hazards in their workplace; requirements for electric equipment and wiring in locations classified as hazardous.



Manual
F414-032-000
 
Filing Suit Against an Electrical Contractor

Instructions for filing suit against an electrical contractor



Formulario
F625-053-000
 
Safety Standards for Construction Work WAC 296-155

Construction work shall mean and include all or any part of excavation, construction, erection, alteration, repair, demolition, and dismantling, of buildings and other structures.



Manual
F414-033-000
 
Chapter 296-56 WAC - Safety Standards - Longshore, Stevedore and Waterfront Related Operations

The rules included in this chapter apply to any and all waterfront operations for longshore, stevedore and waterfront  related operations, cargo handling, and related terminal operations and equipment under the jurisdiction of the  Department of  Labor and  Industries.



Manual
F414-034-000
 
Construction Lien Notice

This form is to be used by suppliers to notify homeowners that they have the ability to file a construction lien against their property if payment is not received.



Formulario
F625-054-000
 
Safety Standards for Fire Fighters WAC 296-305

The rules of this chapter shall apply with respect to any and all activities, operations and equipment of employers and employees involved in providing fire protection services, fire fighters and their work places, including the fire combat scene.

Firefighters are rescuers extensively trained in firefighting, primarily to extinguish hazardous fires that threaten property and civilian or natural populations and to rescue people from dangerous situations, like collapsed or burning buildings.



Manual
F414-036-000
 
Construction Lien Summary

General requirements that a lien claimant of a private construction project (not a commercial) must meet. This is intended show the general requirements for most lien claimants.



Formulario
F625-055-000
 
Safety Standards for Possession, Handling, and Use of Explosives WAC 296-52

Explosives mean any chemical compound or mechanical mixture commonly intended or used for the purpose of producing an explosion.



Manual
F414-038-000
 
Contractor Financial Information

Used by the contractor to request L&I to release assignment of account that they used instead of a surety bond.



Formulario
F625-061-000
 
Chapter 296-24 WAC - General Safety and Health

The rules in this chapter are designed to protect the safety and health of employees by creating a healthy work environment by establishing requirements to control safety hazards in the workplace.



Manual
F414-040-000
 
Affidavit to Release Public Records

This form is to request L&I to release public records in the contractors registration section.



Formulario
F625-066-000
 
Safety Standards for Core Rules WAC 296-800

The Core rules contains basic safety and health rules that affect all employers and should cover almost everything small, nonmanufacturing employers need for a safe and healthful workplace.



Manual
F414-059-000
 
What You Should Know About Hiring a Contractor, Remodeler, or Handyman

Pamphlet/booklet: Provides a checklist for consumers considering hiring a general or specialty construction contractor, reviews the permitting process, and suggests ways to avoid lien problems. Washington State law requires contractors to register with L&I.



Publicaci贸n
F625-084-000

Otro(s) idioma(s):
Espa帽ol
 
Safety Standards for Confined Spaces WAC 296-809

This chapter applies to all confined spaces and provides requirements to protect employees from the hazards of entering and working in confined spaces.



Manual
F414-068-000
 
What to Do if You Want to File Suit Against Your Construction Contractor

Fact sheet: Provides consumers with general information about the process for filing suit, and describes L&I's limited role in serving Summons & Complaint papers.



Publicaci贸n
F625-088-000
 
Workplace Safety and Health Rules and Guides

CD: Contains workplace safety and health rules for Washington State and links to policies and related laws. Also contains guides covering accident prevention programs (APP) and personal protective equipment (PPE). Note: Order CD or view rules online.



CD
F414-074-034
 
Safety Standards for Process Safety Management of Highly Hazardous Chemicals

The purpose this of section, Chapter 296-67 WAC, Process safety management of highly hazardous chemicals, contains requirements for preventing or minimizing the consequences of catastrophic releases of toxic, reactive, flammable, or explosive chemicals. These releases may result in toxic, fire, or explosion hazards.



Manual
F414-090-000
 
Request for Archive Records - Contractor Registration

This form is to request L&I to release archive records in the contractors registration section.



Formulario
F625-094-000
 
Safety Standards for Railroad Clearances and Walkways in Private Rail Yards and Plants WAC 296-860

This chapter applies to all railroad clearances and walkways in rail yards and plants including logging railroad yards such as mill yards, maintenance yards and sorting yards.

To prevent injuries and fatalities to employees by maintaining safe railroad clearances and walkways in your rail yards and plants.



Manual
F414-113-000
 
Chapter 296-842 WAC - Safety Standards - Respirators

An apparatus worn over the mouth and nose or the entire face to prevent the inhalation of dust, smoke, or other noxious substances. Respirator is a type of personal protective equipment designed to protect the wearer from airborne contaminants, oxygen deficiency, or both.



Manual
F414-119-000
 
Contractors: What if You Get a Notice of Infraction?

Pamphlet/booklet: Tells contractors what their options are and what to do if they get a Notice of Infraction (a non-criminal violation). This publication currently unavailable due to revisions in progress. Check back for updates.



Publicaci贸n
F625-097-000
 
Safety Standards Lockout/Tagout WAC 296-803

Lockout/Tagout applies to the service and maintenance of machines and equipment, including piping systems, if employees could be injured by the unexpected energization or start up of the machine or equipment or release of stored energy. Energy sources include mechanical, hydraulic, pneumatic, chemical, thermal, or other energy, including gravity. Machines and equipment include those that produce high intensity electromagnetic fields.



Manual
F414-124-000
 
Application for Electrician Examination

Application and instructions for a Washington State electrician's certificate examination.



Formulario
F626-001-000
 
Safety Standards Machine Safety WAC 296-806

This chapter applies if you have machines or machine operations in your workplace. Machines and their moving parts create the potential for workplace injuries.



Manual
F414-125-000
 
Safety Standards for Forklifts and Other Powered Industrial Trucks WAC 296-863

This chapter applies to powered industrial trucks, electric motors or internal combustion engines, fork trucks, forklifts, tractors, platform lift trucks, motorized hand trucks and other specialized industrial trucks.



Manual
F414-126-000
 
Application / Renewal for an Electrical Training Certificate

This the application for an Electrical Training Certificate or the renewal of. (This does NOT make you a registered apprentice).



Formulario
F626-048-000
 
Safety Standards for Ethylene Oxide WAC 296-855

Ethylene Oxide is a flammable colorless gas that is commonly used to sterilize medical equipment and as a fumigant for certain agricultural products. It is also used as an intermediary in the production of various chemicals such as ethylene glycol, automotive antifreeze, and polyethylene. Exposure is the contact an employee has with ethylene oxide, whether or not protection is provided by respirators or other personal protective equipment (PPE). Exposure can occur through various routes of entry such as inhalation, ingestion, skin contact, or skin absorption.

 



Manual
F414-132-000
 
Safety Standards for Ladders, Portable and Fixed WAC 296-876

This chapter applies to portable and fixed ladders, including job-made wooden ladders, ladder safety, the proper construction, use, placement, and care in handling ladders.



Manual
F414-133-000
 
Application for Plumber Trainee Certificate

This form is used to apply for a plumber trainee certificate.



Formulario
F627-003-000
 
Safety Standards for Administrative Rules WAC 296-900

Administrative Rules and the DOSH Administrative Manual affords employers the right to administrative and judicial review of alleged violations, initial penalties and abatement periods.



Manual
F414-136-000
 
Affidavit of Experience - Plumbers

This form is required to report plumber trainee's plumbing experience for credit towards journey level or specialty status.



Formulario
F627-004-000
 
Safety and Health Discrimination Complaint

Use this form to file a complaint when you feel you've been discriminated against or discharged for reporting a workplace safety hazard.



Formulario
F416-011-000

Otro(s) idioma(s):
Espa帽ol
 
Application for Plumber Examination, Reciprocal, Medical Gas Endorsement, or Temporary Permit

This form is used to apply for plumber examination, reciprocal and medical gas endorsement.



Formulario
F627-008-000
 
Safety and Health Discriminaiton Complaint - (Spanish) Queja de Discriminación de la División de Seguridad Y Salud Ocupacional

Si Usted piensa que ha sido discriminado o despedido por reportar los peligros existentes en su lugar de trabajo, utilice este formulario para presentar una queja.



Formulario
F416-011-999

Otro(s) idioma(s):
Ingl茅s
 
Request for Duplicate or Replacement Certificate

This form is used to request a duplicate or replacement certificate for a plumber or plumber trainee.



Formulario
F627-014-000
 
Safety and Health Workshops

Pamphlet/Brochure: Introduces free workshops to help employers prevent workplace injuries and control workers' compensation costs. Includes course descriptions, and how to register.



Publicaci贸n
F416-036-000
 
Job Safety and Health Law - Spanish Ley de Seguridad y Salud en el Trabajo (English/Spanish)

Required poster: Describes important parts of the Washington Industrial Safety and Health Act (WISHA), which provides for job safety and health of Washington employees. Note: Employers in Washington State must display this poster where workers can see it. When ordering the printed version, you will receive one 22" X 17" poster that includes both languages.

Please order from L&I or print on 11" x 17" paper.

Get poster printing tips.



Cartel
F416-081-909
 
Plumber, Medical Gas, or Trainee Renewal

This form is used to renew a plumber certification, plumber trainee or medical gas installer certification.



Formulario
F627-019-000
 
Facts about State Certification for Plumbers
Fact sheet: Explains plumber classifications, certification requirements, including required exams, and the application and renewal processes, including continuing education requirements.

Publicaci贸n
F627-022-000
 
A Guide to Workplace Safety and Health in Washington State

Pamphlet/booklet: Provides an overview of the Washington Industrial Safety and Health Act (WISHA), worker and employer rights and responsibilities, enforcement of WISHA rules, and consultation and education services L&I provides. Previously titled A Guide to WISHA



Publicaci贸n
F416-132-000

Otro(s) idioma(s):
Espa帽ol
 
Facts about Medical Gas Piping Installer Endorsement
Fact sheet: Explains training requirements and the endorsement process for medical gas piping installers.

Publicaci贸n
F627-026-000
 
A Guide to Workplace Safety and Health in Washington State-Spanish (Una Guía de Seguridad y Salud del Lugar de Trabajo en el Estado de Washington)

Pamphlet/booklet: Provides an overview of the Washington Industrial Safety and Health Act (WISHA), worker and employer rights and responsibilities, enforcement of WISHA rules, and consultation and education services L&I provides. Previously titled A Guide to WISHA



Publicaci贸n
F416-132-999

Otro(s) idioma(s):
Ingl茅s
 
Logging Emergency Medical Plan (Logging Safety and Health Meetings)

Use this two part form for employers to record work locations and emergency rescue info and for holding safety meetings for each new jobsite



Formulario
F417-014-000
 
Plumbers Examination Dates and Locations

The 2014 Plumber Examination Dates and Locations. A printed version is also available from the L&I Warehouse.



Formulario
F627-027-000
 
Forklift Safety Guide
Book: Provides general information on kinds of forklifts, principles of physics that apply to forklifts, training requirements for forklift operators, basic operator safety rules, dangers of carbon monoxide, and safety while servicing a forklift.

Publicaci贸n
F417-031-000
 
Application for Backflow Trainee Certificate

This form is used to apply for a backflow trainee certificate.



Formulario
F627-033-000
 
Guide to Crew Safety Meetings
Pamphlet/booklet: Provides a succinct guide to conducting crew safety meetings for general industry and the construction industry. Includes a format for recording meeting minutes.

Publicaci贸n
F417-043-000
 
Crew Leader Safety Meeting

Use this form to document the minutes of your safety meetings.



Formulario
F417-049-000
 
Application for Backflow Specialty Exam

This form is used to apply for the backflow specialty examination.



Formulario
F627-035-000
 
Safety Meeting Minutes

Use this form to record the minutes from your safety meetings - these records must be retained for one year from the date of each meeting



Formulario
F417-087-000

Otro(s) idioma(s):
Espa帽ol
 
Safety Meeting Minutes - Spanish - Actas De La Reúnion de Seguridad

Use this form to record the minutes from your safety meetings - these records must be retained for one year from the date of each meeting



Formulario
F417-087-999

Otro(s) idioma(s):
Ingl茅s
 
Plumber Continuing Education Course Application

This form is used by the course sponsor to submit continuing education courses for plumber certification.



Formulario
F627-037-000
 
Safety and Health Discrimination in the Workplace (English/Spanish)/ Discriminación de seguridad y salud en el lugar de trabajo

Poster: Employees have the right to report concerns about safety and health in their workplace. This poster describes "protected activities" under the Washington Industrial Safety and Health Act (WISHA) and explains what an employee should do if he/she has been punished or fired for exercising these rights. Get poster printing tips.



Cartel
F417-188-909
 
Parent / School Authorization for Employment of a Minor and Special Variance

For legal guardians and school officials to approve the hours and work activities for a minor employee to work according to terms listed by the employer. The Special Variance allows additional hours of work for 16- and 17-year-olds and is described on the form. All parties must sign to approve the hours of work for a minor regardless of the number of hours listed. This is NOT a work permit. Employers must obtain a minor work permit endorsement on their Master Business License where they employ workers under 18.

For hiring youth only during non-school weeks, you may use form F700-168-000 Parent Authorization Summer Work  



Formulario
F700-002-000
 
Forklift Safety: Training requirements and helpful tips

Fact sheet: Provides answers to the most-often asked questions about forklift training. Includes a checklist that employer may use to document that employees have been trained and/or evaluated in the required topics.



Publicaci贸n
F417-202-000
 
Borrower Agreement Form Safety and Health Video Library

Borrower Agreement Form - To open an account and borrow videos, please fill out this form.



Formulario
F417-205-000
 
Affidavit of Wages Paid - Public Works Contract and Instructions

This form is a fillable Word document that is used by a contractor, company or agency to show the wages paid to employees on a public works project. The best way to use this document is to bookmark this page as a “Favorite” in your web browser. Then each time when you want to use the document, access the online version of the form. This will ensure you are always utilizing the most recently published form. (We recommend you not download the document and save the form for future use because we may make changes to the form that your downloaded version will not contain.) You must file the Affidavit of Wages Paid form when you have completed your portion of a public works job/project. Addendum A is form number F700-161-000, Addendum C is form number F700-162-000, and the EHB 2805 (RCW 39.04.370) Addendum is form number F700-164-000.



Formulario
F700-007-000
 
Reservation Form Safety and Health Video Library

Use this form to make reservations of safety and health videos. There is both a fillable MS Word form that you can email in, and a fillable PDF that you can fill and print.



Formulario
F417-206-000
 
Record Keeping Provisions - Employment Standards

This form is for employers to use to keep records on every employee.



Formulario
F700-009-000
 
Safety & Health Video Library & Resource Center
Pamphlet: Introduces the center and available services. You can borrow safety training videos and DVDs and order workplace posters. Also contains contact information.

Publicaci贸n
F417-222-000
 
Application for Farm Labor Contractor License

Used to apply or renew a license.



Formulario
F700-014-000
 
Safety and Health Investment Projects (SHIP) Grant Program

Booklet: Introduces the SHIP Grant Program and application process. SHIP awards grants for innovative projects that (1) prevent workplace injuries, illnesses and deaths and (2) encourage injured workers to return to work early and reduce long-term disability.



Publicaci贸n
F417-224-000
 
Safety for Commercial Dive Teams
Fact sheet: Provides an overview of safety for commercial dive teams, summarizes the key requirements of commercial diving regulations (WAC 296-37), and includes contact information.

Publicaci贸n
F417-226-000
 
Teens at Work: Facts for Employers, Parents and Teens

Pamphlet/booklet: Answers questions employers, parents and teens may have about employing teen workers (ages 14-17). Explains non-agriculture work rules, including the necessary permits, hours and work conditions. Provides links to other resources.



Publicaci贸n
F700-022-000

Otro(s) idioma(s):
Espa帽ol
 
Wage Transcription and Computation Sheet

Employer uses this to show time worked and wages earned for an employee.



Formulario
F700-024-000
 
Safety and Health Program Assessment Worksheet

Safety and Health Program Assessment Worksheet



Formulario
F417-227-000
 
Prevailing Wage Complaint and Instructions

Ask L&I to conduct an investigation into a prevailing wage violation that affects one or more employees. See box 30 on the form to see what types of complaints are covered.



Formulario
F700-146-000

Otro(s) idioma(s):
Espa帽ol
 
START Program (Safety through Achieving Recognition Together)
Fact sheet: Provides an overview of START, a program that recognizes occupational safety and health excellence in small businesses. Includes program requirements and benefits.

Publicaci贸n
F417-229-000
 
Nail Gun Safety: A Guide for Construction Contractors

Booklet: Gives information needed to prevent nail gun injuries for construction employers.



Publicaci贸n
F417-232-000
 
Prevailing Wage Complaint Instructions - Spanish - Instrucciones para el Registro de una Queja Sobre Salario Prevaleciente

Ask L&I to conduct an investigation into a prevailing wage-related issue that affects one or more employees.



Formulario
F700-146-999

Otro(s) idioma(s):
Ingl茅s
 
Tractor Safety: Rollover Protection and Seatbelts

Pamphlet: Summarizes the safety rules for rollover protective structures (ROPS) and seatbelts on tractors. Also lists exemptions and provides other information about safe operation of tractors.



Publicaci贸n
F417-234-000

Otro(s) idioma(s):
Espa帽ol
 
Tractor Safety: Rollover Protection and Seatbelts (Seguridad con los tractores: Proteccin contra vuelcos ylos cinturones de seguridad)
Pamphlet: Summarizes the safety rules for rollover protective structures (ROPS) and seatbelts on tractors. Also lists exemptions and provides other information about safe operation of tractors.

Publicaci贸n
F417-234-999

Otro(s) idioma(s):
Ingl茅s
 
Workplace Safety and Health Pocket Guide

Pocket guide: Provides links to online information, including safety and health consultations, how to develop a safety program, reporting hazards and injuries, other safety training, and information for teen workers.



Publicaci贸n
F417-241-000
 
Statement of Intent to Pay Prevailing Wages - Public Works Contract

This form is a fillable Word document that is used by a contractor, company or agency upon accepting work on a public works project. The best way to use this use this document is to bookmark this page as a “Favorite” in your web browser. Then each time when you want to use the document, access the online version of the form. This will ensure you are always utilizing the most recently published form. (We recommend you not download the document and save it for future use because we may make changes to the form that your downloaded version will not contain.) You should file this form immediately after the contract is awarded and before you begin work. Form number F700-160-000 is addendum A and F700-163-000 is addendum C.



Formulario
F700-029-000
 
Safety and Health Discrimination in the Workplace

Brochure: Employees have the right to report concerns about safety and health in their workplace. This brochure describes "protected activities" under the Washington Industrial Safety and Health Act (WISHA) and explains what an employee should do if he/she has been punished or fired for exercising these rights.



Publicaci贸n
F417-244-000

Otro(s) idioma(s):
Espa帽ol
 
Agreement - Farm Labor Contractors and Workers

Employment wages and conditions agreement with Farm Labor Contractors and Workers



Formulario
F700-046-000

Otro(s) idioma(s):
Espa帽ol
 
Agreement - Farm Labor Contractors and Workers - Spanish - Acuerdo entre Contratistas Agrícolas y Trabajadores

Employment wages and conditions agreement with Farm Labor Contractors and Workers



Formulario
F700-046-999

Otro(s) idioma(s):
Ingl茅s
 
Discriminación de seguridad y salud en el lugar de trabajo (Safety and Health Discrimination in the Workplace)

Folleto: Los empleados tienen derecho a reportar sus inquietudes sobre seguridad y salud en sus lugares de trabajo.  Este folleto describe las “actividades protegidas": bajo la Ley de Seguridad y Salud Industrial de Washington (WISHA, por su sigla en inglés) y explica lo que debe hacer un empleado si él/ella es castigado o despedido por ejercer estos derechos.



Publicaci贸n
F417-244-999

Otro(s) idioma(s):
Ingl茅s
 
Farm Labor Contractor Assignment of Account or Time Deposit

Farm Labor Contractor assignment of account or tme deposit for employee



Formulario
F700-060-000
 
Payment of Wages - RCW 49.48.010 and 49.52.050

This is a copy of the law that pretains to the payment of wages to an employee when they stop working for an employer. The wages due to the employee for the pay period worked prior to leaving.



Formulario
F700-064-000
 
2014 Workplace Safety and Health Calendar: Top 12 Hazards that Cause Injuries and Deaths

Calendar: Features real Washington State businesses and employees handling typical workplace hazards and spotlighting the top 12 hazards that cause injuries and deaths. It includes suggested weekly safety and health tips for different hazards, including slips trips and falls, struck by falling objects, burns and more.



Publicaci贸n
F417-248-000
 
Certified Project Payroll

There are instructions in one PDF file, and a blank form that may be printed in the other PDF. The word document is saved in Microsoft 2003 format and is a fillable word form.



Formulario
F700-065-000
 
Logger Safety Initiative Jobsite Notification

Members of the Logger Safety Initiative and landowners use this form to report their jobsite to L&I.



Formulario
F417-249-000
 
Alleged Safety Or Health Hazards (DOSH Complaint Form)

Employees use this form to report work place conditions which jeopardize workers safety and health.



Formulario
F418-052-000

Otro(s) idioma(s):
Espa帽ol
 
Farm Labor Contractors Bond

Notarized farm labor contractors bond coverage.



Formulario
F700-066-000
 
What Are Your Rights When You Work for a Farm Labor Contractor? (English/Spanish) / 驴Cúales son sus derechos cuando trabaja para un contratista de trabajadores agrícolas?
Fact sheet: Explains workers' rights when they are employed by a farm labor contractor. Topics covered include workplace safety, rest and meal breaks, and help if injured on the job.

Publicaci贸n
F700-067-909
 
Alleged Safety Or Health Hazards (DOSH Complaint Form) Spanish - Presuntos Riesgos de Salud y Seguridad (Formulario de Queja de DOSH)

Employees use this complaint form to report work place conditions which jeopardize workers safety and health.



Formulario
F418-052-999

Otro(s) idioma(s):
Ingl茅s
 
Your Rights as a Worker in Washington State/ Sus Derechos como Trabajador en el Estado de Washington (English/Spanish)

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
F700-074-909
 
Construction Checklist - Safety

Construction Checklist - Safety



Formulario
F418-055-000

Otro(s) idioma(s):
Espa帽ol
 
Variance Application - For exceptions from specific rules governing employment of minors.

Employer uses this application for requesting a variance to employment regulations for minors.



Formulario
F700-076-000
 
Construction Checklist - Safety - Spanish - Lista de Verificación de Seguridad en la Construcción

Construction Checklist - Safety - Spanish - Lista de verificación de seguridad en la construcción



Formulario
F418-055-999

Otro(s) idioma(s):
Ingl茅s
 
Farm Labor Contractor Registration

Fact Sheet: Explains how to get a farm labor contractor license in order to operate legally as a farm labor contractor in Washington State.



Publicaci贸n
F700-088-000

Otro(s) idioma(s):
Espa帽ol
 
Electrical Safety Standards,Administration, and Installation WAC 296-46B

Electrical Safety Standards,Administration, and Installation WAC 296-46B



Manual
F500-039-222
 
Variance Application - Employment Standards

Employer application request for a variance from employment standards for non minor employees.



Formulario
F700-089-000
 
Questions and Answers about Electrical Safety
Fact Sheet: Answers questions about training and certification/licensing requirements for those who perform electrical installations, and electrical work that requires a permit and inspection.

Publicaci贸n
F500-110-000
 
Young Workers in Agriculture/Trabajadores j贸venes en la agricultura (English/Spanish)

Pamphlet/booklet: Answers many questions employers and minor workers have about employing minors. Covers agriculture work rules, including the necessary permits, hours and work conditions for workers 12-17 years of age.



Publicaci贸n
F700-096-909
 
Internal Revenue Service Tax Compliance Certification

Form to gain Internal Revenue Service Tax Compliance Certification for registered Farm Labor Contractors. Now includes IRS form 8821 Tax Information Authorization.



Formulario
F700-098-000
 
Department of Employment Security Tax Compliance Certification

Form to gain Department of Employment Security Tax Compliance Certification for registered Farm Labor Contractors.



Formulario
F700-099-000
 
Electrical Safety Tips for Your Home: Protect Your Family and Your Property
Pamphlet/Booklet: Provides information to help consumers properly handle electrical equipment and appliances, know the required permits and inspections for electrical work, and verify licenses and certifications before having electrical work performed.

Publicaci贸n
F500-115-000
 
Department of Revenue Tax Compliance Certification

Form to gain Department of Revenue Tax Compliance Certification for registered Farm Labor Contractors.



Formulario
F700-100-000
 
Your Daily Record of Hours Worked (English/Spanish) / Su Registro de Horas Trabajadas
Pamphlet/booklet: A pocket-sized bilingual booklet to encourage agricultural workers to keep track of their daily work hours and earnings.

Publicaci贸n
F700-105-909
 
Farm Labor Contractor Complaint Form

Used to file a complaint against a Farm Labor Contractor, landowner, employer, or other where a possible infraction is concerned.



Formulario
F700-109-000

Otro(s) idioma(s):
Espa帽ol
 
Formulario de Queja en Contra de un Contratista de Trabajores Agrícolas (Farm Labor Contractor Complaint)

Used to file a complaint against a Farm Labor Contractor, landowner, employer, or other where a possible infraction is concerned.



Formulario
F700-109-999

Otro(s) idioma(s):
Ingl茅s
 
RCW 43.22.380 Exemptions Fire and Safety Checklist for Vendor/Medical Conversion Units
Generic Checklist to determine if the particular installation includes all requirements prior to calling for an inspection. Must be able to answer YES to all questions prior to calling.

Formulario
F622-073-000
 
Farm Labor Contractor Checklist

Farm Labor Contractor's Checklist to ensure compliance.



Formulario
F700-112-000

Otro(s) idioma(s):
Espa帽ol
 
Operating Power Lawn and Yard-care Equipment: Safety for Teen Workers
Fact sheet: Overview of safety practices, plus information on what equipment employees under 18 can and cannot operate. Provides resources on requirements for hearing protection and PPE (personal protective equipment).

Publicaci贸n
F700-010-000
 
Employing Children Under Age 14 in Non-Agricultural Jobs

Fact sheet: Explains when employers can and cannot employ minors under age 14 in non-agricultural jobs. Details the process for obtaining court permission when hiring minors under 14 is allowed.



Publicaci贸n
F700-117-000
 
Safety Steps for Supervisors and Employees in Restaurants
Fact Sheet: A useful summary of the responsibilities both employers and employees share for a safe workplace. This can be shared with new employees during their initial orientation.

Publicaci贸n
F700-139-000
 
Employer Petition to The Court for Minor Work Permit Under Age 14

Petition to The Court for Minor Work Permit Under Age 14 by Employer.



Formulario
F700-118-000
 
Restaurant Employee Safety Orientation Checklist
Fact Sheet: Download this checklist to help with the safety orientation of new restaurant employees.

Publicaci贸n
F700-140-000
 
Court Form Granting Permission for Employment of Minors

Form from Court Granting Permission for Employment of Minors to the employer.



Formulario
F700-119-000
 
Safety Comes Thru Job Training
A supervisor having a discussion with his crew. Get poster printing tips.

Cartel
FSP0-901-000
 
Application for Special Certificate to Employ at A Subminimum Wage Rate

Employer Application for Special Certificate to Employ at A Subminimum Wage Rate.



Formulario
F700-120-000
 
Fryer Safety
Tips on deep frying safety. Get poster printing tips.

Cartel
FSP0-905-000
 
Application for Special Certificate to Employ A Vocationally Handicapped Worker at at Subprevailing Wage Rate

Employer Application for Special Certificate to Employ A Vocationally Handicapped Worker at at Subprevailing



Formulario
F700-122-000
 
Job Site Safety: Wear Your Hard Hat
Poster: Visual reminder you can print for posting at appropriate job sites and use in safety training, crew or safety committee meetings.

Cartel
FSP0-907-000
 
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):
Espa帽ol
 
The Best Accident Insurance - To observe all safety regulations
Picture of a guy with Saftey Policy and Rules in his hand. Get poster printing tips.

Cartel
FSP0-915-000
 
Application for Benefits - Crime Victims

Used by victims of a crime in Washington State to receive benefits for time lost from work, loss of financial support, medical or mental health treatment. The Spanish version of the instructions are online as F800-042-999.



Formulario
F800-042-000

Otro(s) idioma(s):
Espa帽ol
 
Ladder Safety
Picture of a ladder with safety tips on the rungs. Get poster printing tips.

Cartel
FSP0-951-000
 
Application for Benefits- Crime Victims Spanish - Instrucciones para: Solicitud para Beneficios para Víctimas de Crimen

Instructions in Spanish to complete the English form F800-042-000 Application for Crime Victim benefits. The form is used by victims of a crime in Washington State to receive benefits for time lost from work, loss of financial support, medical or mental health treatment. This 12-10 version is internet only.



Formulario
F800-042-999

Otro(s) idioma(s):
Ingl茅s
 
Keys to Safety
Picture of two keys with the words 'Skills' and Knowledge' on them. Get poster printing tips.

Cartel
FSP0-954-000
 
Request for Survivor Counseling Benefits (English/Spanish) Solicitud para Beneficios de Apoyo para los Sobrevivientes  

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



Formulario
F800-057-909
 
Safe Ways - Fork Lift Safety
Safety tips on using a fork lift. Get poster printing tips.

Cartel
FSP0-978-000
 
Crime Victims Statement for Pharmacy Services

Used by Crime Victims Compensation Program providers to bill for pharmacy services. Crime Victims Compensation Program providers are required to bill using this form.



Formulario
F800-058-000
 
Know Your Lockout Tagout Safety Procedures
Poster: Visual reminder you can print for posting in appropriate workplaces. Two options available for download and/or printing.

Cartel
FSP1-063-000
 
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
 
Employers’ Guide to Workers’ Compensation Insurance in Washington State

Book: Explains the Washington State's workers' compensation program. Suggests ways to protect workers' safety and health and describes L&I programs to help employers control premium costs.



Publicaci贸n
F101-002-000
 
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
 
Crime Victims Statement for Home Nursing Services

Used by the Crime Victims Compensation Program providers for reimbursement of home nursing services. Crime Victims Compensation Program providers are required to bill using this form.



Formulario
F800-070-000
 
What Are Your Rights as a Worker? (English/Russian)
Fact sheet: Provides a brief overview of the worker rights administered by the Department of Labor and Industries. These include certain employment-related rights and rights pertaining to workplace safety and workers' compensation benefits.

Publicaci贸n
F101-061-404

Otro(s) idioma(s):
Ingl茅s/釣釣樶煉釣栣灮釣囜灦
Ingl茅s/頃滉淡鞚
Ingl茅s/Espa帽ol
Ingl茅s/Vi峄噒
 
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.



Publicaci贸n
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
 
What Are Your Rights as a Worker? (English/Vietnamese)
Fact sheet: Provides a brief overview of the worker rights administered by the Department of Labor and Industries. These include certain employment-related rights and rights pertaining to workplace safety and workers' compensation benefits.

Publicaci贸n
F101-061-505

Otro(s) idioma(s):
Ingl茅s/釣釣樶煉釣栣灮釣囜灦
Ingl茅s/頃滉淡鞚
Ingl茅s/褉褍褋褋泻懈泄
Ingl茅s/Espa帽ol
 
Crime Victims Compensation Program Initial Response and Assessment: Form I
Used by the clinical provider to get approval to see a victim for six sessions or less. If more than six sessions, please complete Form II (F800-081-000).

Formulario
F800-080-000
 
Crime Victims Compensation Program Initial Response and Assessment: Form II

Used by the clinical provider to request authorization to provide more than six sessions. This form must be submitted by the sixth session. (6 pages)



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

Used by the clinical provider to submit a request for preauthorization for payment of additional sessions.



Formulario
F800-082-000
 
What Are Your Rights as a Worker? (English/Cambodian)
Fact sheet: Provides a brief overview of the worker rights administered by the Department of Labor and Industries. These include certain employment-related rights and rights pertaining to workplace safety and workers' compensation benefits.

Publicaci贸n
F101-061-606

Otro(s) idioma(s):
Ingl茅s/頃滉淡鞚
Ingl茅s/褉褍褋褋泻懈泄
Ingl茅s/Espa帽ol
Ingl茅s/Vi峄噒
 
Crime Victims Compensation Program Treatment Report: Form IV

Used by the clinical provider to request preauthorization for payment of additional sessions.



Formulario
F800-083-000
 
Poster - An Unprotected Trench is an Early Grave

Poster: Trench safety information for employers. Features tips to prevent cave-ins, and proper inspection proceedures. Get poster printing tips.



Cartel
FSP0-912-000
 
Caution: Hard Hat Area
Visual reminder of the importance of wearing a hard hat. Get poster printing tips.

Cartel
FSP0-928-000

Otro(s) idioma(s):
Espa帽ol
 
What Are Your Rights as a Worker? (English/Korean)
Fact sheet: Provides a brief overview of the worker rights administered by the Department of Labor and Industries. These include certain employment-related rights and rights pertaining to workplace safety and workers' compensation benefits.

Publicaci贸n
F101-061-707

Otro(s) idioma(s):
Ingl茅s/釣釣樶煉釣栣灮釣囜灦
Ingl茅s/褉褍褋褋泻懈泄
Ingl茅s/Espa帽ol
Ingl茅s/Vi峄噒
 
Precaución: Obligatorio Usar Casco
Picture of hard hats. Get poster printing tips.

Cartel
FSP0-928-999

Otro(s) idioma(s):
Ingl茅s
 
Siempre Use Protección para los ojos
Picture of a large eye with some content on when to use eye protection. Get poster printing tips.

Cartel
FSP0-940-999

Otro(s) idioma(s):
Ingl茅s
 
Always Wear Eye Protection

Sticker: 7.25 inches X 4.25 inches.



Calcoman铆a
FSP0-941-000
 
What Are Your Rights as a Worker?

Fact sheet: Provides a brief overview of the worker rights administered by the Department of Labor and Industries. These include certain employment-related rights and rights pertaining to workplace safety and workers' compensation benefits.



Publicaci贸n
F101-061-909

Otro(s) idioma(s):
Ingl茅s/釣釣樶煉釣栣灮釣囜灦
Ingl茅s/頃滉淡鞚
Ingl茅s/褉褍褋褋泻懈泄
Ingl茅s/Vi峄噒
 
Danger! Minimum Clearance for Counter Balance - Construction

Sticker: 30 inches long.



Calcoman铆a
FSP0-974-000
 
Put this Guard Back - 8.5 x 3.5 inches

Sticker: 8.5 inches X 3.5 inches



Calcoman铆a
FSP0-993-000

Otro(s) idioma(s):
Espa帽ol
 
Guía para Contratar Contratistas Independientes en el Estado de Washington

Pamphlet/booklet: Designed to help employers determine if their workers are employees or independents under Washington's workers' compensation, workplace safety, wage and hour and unemployment tax laws. Includes a short "test" and helpful references.



Publicaci贸n
F101-063-999

Otro(s) idioma(s):
Ingl茅s
 
Put this Guard Back - 5 1/2 x 2 1/8 inches

Sticker: 5 1/2 inches X 2 1/8 inches



Calcoman铆a
FSP0-993-001

Otro(s) idioma(s):
Espa帽ol
 
 Si usted TIENE que remover este resguardo 8.5 x 5.5

Sticker: 8.5 inches X 3.5 inches



Calcoman铆a
FSP0-993-999

Otro(s) idioma(s):
Ingl茅s
 
An Employer's Intro to L&I

Info card: Provides information on the Employer's Intro to L&I workshop, including statewide schedule of workshops. Designed for employers and managers, the workshop covers a number of topics, including workers' compensation insurance, workplace safety, and overtime.



Publicaci贸n
F101-101-000
 
Grinding Wheel - Prevent Accidents

Sticker size 4"x3"



Calcoman铆a
FSP1-000-000
 
Monthly Supplemental Report for Manual Logging

Used by employers enrolled in the Logger Safety Initiative (LSI) to report manual logging hours monthly.



Formulario
F212-246-000
 
Report All Injuries Promptly
Large words: Report All Injuries Promptly. Get poster printing tips.

Cartel
FSP1-004-000

Otro(s) idioma(s):
Espa帽ol
 
Long Term Care Assessment Tool

You must mail or fax form. No emailed forms are accepted. This assessment tool is provided by L&I assessment to determine the medically appropriate level of care that will meet the Injured Worker’s needs, abilities and safety in a residential facility. This assessment is not intended as a substitute for DSHS annual assessment & treatment plan, which is the sole financial responsibility of the facility.



Formulario
F245-377-000
 
Reporte Todas las Lesiones Inmediatamente

Large words: Report All Injuries Promptly. Get poster printing tips.



Cartel
FSP1-004-999

Otro(s) idioma(s):
Ingl茅s
 
Asbestos Abatement Project Notice of Intent and L&I DOSH Asbestos Program

Notice is not required for any asbestos project involving less than forty-eight (48) square feet of surface area, or less than ten (10) linear feet of pipe unless the surface area of the pipe is greater than forty-eight (48) square feet. Get instructions to complete the form.



Formulario
F413-025-000
 
First Aid

Safety Sticker size 5"x6"



Calcoman铆a
FSP1-005-000
 
Danger, Workers Above
Picture of workers on a high rise. Get poster printing tips.

Cartel
FSP1-012-000

Otro(s) idioma(s):
Espa帽ol
 
Variance Application - IND S&H

Use this form to apply for a variance for an allowed deviation from a specific safety or health standard when an employer substitutes measures which afford an equal degree of safety.



Formulario
F414-021-000
 
Danger, Workers Above-Spanish (Peligro - Trabajadores en el Nivel Superior)

Picture of workers on a high rise. Get poster printing tips.



Cartel
FSP1-012-999

Otro(s) idioma(s):
Ingl茅s
 
Danger, Construction Area Authorized Personnel Only
Large words: Danger, Construction Area Authorized Personnel Only. Get poster printing tips.

Cartel
FSP1-013-000

Otro(s) idioma(s):
Espa帽ol
 
Peligro - Área en Construcción - Solamente Personas Authorizadas

Large words: Peligro - Área en Construcción -  Solamente Personas Authorizadas. Get poster printing tips.



Cartel
FSP1-013-999

Otro(s) idioma(s):
Ingl茅s
 
Commercial Diving Operations, Chapter 296-37 WAC

This manual contains basic safety and health rules that affect all employers and should cover almost all commercial diving operations. This manual also covers search and rescue and other public safety diving operations.



Manual
F414-039-000
 
Danger
Large lettering: DANGER. Get poster printing tips.

Cartel
FSP1-030-000

Otro(s) idioma(s):
Espa帽ol
 
Cartel - PELIGRO

Large lettering: PELIGRO



Cartel
FSP1-030-999

Otro(s) idioma(s):
Ingl茅s
 
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):
Espa帽ol
 
The DOSH Consultation Manual

The DOSH Consultation Manual provides guidance regarding some of the internal operations of L&I and the Division of Occupational Safety and Health (DOSH). The contents of the manuals are not enforceable by any person or entity against the Department of Labor and Industries or the State of Washington.



Manual
F414-151-000
 
Notificación de Decisión de Cierre para Reclamos Únicamente Médicos para Empleadores Autoasegurados

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
F207-020-999

Otro(s) idioma(s):
Ingl茅s
 
Notificación de Decisión de Cierre para reclamos de Tiempo Perdido para Empleadores Autoasegurados

Used by self-insured employers or their representatives, this is legal notification to an injured worker that their claim is being closed. This order is used only when time loss compensation has been paid, but no permanent partial disability award is being paid.



Formulario
F207-070-999

Otro(s) idioma(s):
Ingl茅s
 
Notificación de Decisión de Cierre con Discapacidad Parcial Permanente para Empleadores Autoasegurados - PPD-TL

Used by self-insured employers or their representatives only, this is legal notification to an injured worker that their claim is being closed. This order is used only when time loss compensation has been paid, and a permanent partial disability award is also being paid.



Formulario
F207-164-999

Otro(s) idioma(s):
Ingl茅s
 
Keep Your Employees Safe and Working

Pamphlet/booklet: Describes the benefits of free employer consultations offered by L&I's Division of Occupational Safety and Health (DOSH). These services include on-site safety and/or industrial hygiene consultations, ergonomics assistance and risk management advice.



Publicaci贸n
F417-209-000

Otro(s) idioma(s):
Espa帽ol
 
Keep Your Employees Safe and Working - Spanish (Mantenga a sus empleados seguros y trabajando)

Pamphlet/booklet: Describes the benefits of free employer consultations offered by L&I's Division of Occupational Safety and Health (DOSH). These services include on-site safety and/or industrial hygiene consultations, ergonomics assistance and risk management advice.



Publicaci贸n
F417-209-999

Otro(s) idioma(s):
Ingl茅s
 
Notificación de Decisión de Cierre con Discapacidad Parcial Permanente para Empleadores Autoasegurados - PPD-NTL

Used by self-insured employers or their representatives only, this is legal notification to an injured worker that their claim is being closed. This order is used only when time loss compensation has not been paid, but a permanent partial disability award is being paid.



Formulario
F207-165-999

Otro(s) idioma(s):
Ingl茅s
 
A Safe and Healthy Workplace Begins with You
Pamphlet: Provides an overview of employers' responsibilities for workplace safety and health in Washington State. Covers free L&I services, including workplace consultations, online training and prevention resources and required posters. Intended for new businesses or businesses hiring employees for the first time.

Publicaci贸n
F417-210-000
 
Jorge's New Job: Cholinesterase Testing in Washington State - Spanish Un Nuevo Trabajo para Jorge(English/Spanish)

Pamphlet/booklet: Uses a story format with dialogue and photographs to explain the hazards of cholinesterase-inhibiting pesticides, the state's monitoring program and the importance of using proper safety equipment when working with pesticides.



Publicaci贸n
F417-213-909
 
Voluntary Protection Program (VPP)
Fact sheet: Provides an overview of the VPP, a program that recognizes occupational safety and health excellence. Identifies benefits and includes testimonials from companies awarded VPP status.

Publicaci贸n
F417-221-000
 
Hearing Services Worker Information

This is a list of the rights and conditions when an injured worker applies for hearing aids.



Formulario
F245-049-000
 
Termination of Agreement (Rescission)
To be filled out by the injured worker who wants to return hearing aids.

Formulario
F245-050-000
 
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):
Espa帽ol
 
Comentarios Sobre el Ex谩men M茅dico Independente
Used by the injured worker to provide comments to L&I about their recent medical exam by an IME.

Formulario
F245-053-999

Otro(s) idioma(s):
Ingl茅s
 
Application for Replacement of Lost or Stolen Asbestos Certification Card

This application is for any certified asbestos worker or supervisor that has lost or had their card stolen.



Formulario
F413-068-000
 
Chemical Hazard Communication: Helpful information for employers (Vietnamese)
Book: Provides employers a checklist on the requirements of the chemical hazard communication rule. Contains an extensive question-and-answer section and information on starting an employee-training program.

Publicaci贸n
F413-012-555

Otro(s) idioma(s):
涓浗鐨
Ingl茅s
頃滉淡鞚
Espa帽ol
 
Chemical Hazard Communication: Helpful information for employers (Korean)
Book: Provides employers a checklist on the requirements of the chemical hazard communication rule. Contains an extensive question-and-answer section and information on starting an employee-training program.

Publicaci贸n
F413-012-777

Otro(s) idioma(s):
涓浗鐨
Ingl茅s
Espa帽ol
Vi峄噒
 
Washington State Top 25 Hazardous Industries

Booklet: Provides a summary of occupational injury and illness data, including safety and health violations cited, by the top 25 hazardous industries for the five-year period 2006 to 2010.



Publicaci贸n
F417-243-000
 
Chemical Hazard Communication: Helpful information for employers (Chinese)
Book: Provides employers a checklist on the requirements of the chemical hazard communication rule. Contains an extensive question-and-answer section and information on starting an employee-training program.

Publicaci贸n
F413-012-888

Otro(s) idioma(s):
Ingl茅s
頃滉淡鞚
Espa帽ol
Vi峄噒
 
Comunicación sobre Peligros Químicos: Información Útil para los Empleadores

Book: Provides employers a checklist on the requirements of the chemical hazard communication rule. Contains an extensive question-and-answer section and information on starting an employee-training program.



Publicaci贸n
F413-012-999

Otro(s) idioma(s):
涓浗鐨
Ingl茅s
頃滉淡鞚
Vi峄噒
 
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):
Espa帽ol
 
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):
Espa帽ol
 
Renewal of Elevator Mechanic License

Used by elevator mechanics to renew their license if they do not want to use the online "Get or Renew a License".



Formulario
F621-080-000
 
Application for a 0% Supervision Modified Electrical Training Certificate & Specialty Examination

Covers 03A, 06B, 07A, 07B, 07C, 07D, 07E, and 10 specialty licenses.



Formulario
F500-097-000
 
Electrical Installation Variance Application

To apply for a variance which is an allowable deviation from specific requirements of a National Electrical Code section, or the WAC 296-46B where the proposed alternate methods will maintain equivalent safety.



Formulario
F500-063-000
 
Operating Boilers Safely
Fact sheet: Explains what you need to know to keep your boilers and pressure vessels operating safety. Provides an overview of inspection requirements, frequency and fees.

Publicaci贸n
F620-025-000
 
Application for Specialty Electrician Certificate

Application and instructions for the specialty electrician certificate for 03A, 06B, 07A, 07B, 07C, 07D, 07E and 10. Eligibility granted through modified supervision requirements of RCW 19.28.191(1)(g)(ii)



Formulario
F500-098-000
 
Keep Your Water Heater Safe
Pamphlet/booklet: Describes the process for conducting an annual safety test of a residential water heater. Includes illustrations.

Publicaci贸n
F620-048-000
 
Faulty Water Heaters and Kids Don't Mix
Fact sheet: Designed for operators of childcare facilities, this fact sheet explains the importance of keeping boilers and pressure vessels operating safety. Provides an overview of inspection requirements, frequency, and fees.

Publicaci贸n
F620-059-000
 
Minimum Wage Law Exemptions

Covers exemptions to Washington state minimum wage law.



Publicaci贸n
F700-051-000
 
Employer Rights - Wages Paid

Covers penalties for employer wage violations. Once stock runs out in warehouse, this form will be internet only.



Formulario
F700-058-000
 
Employment History Form Spanish Formulario de Historial de Empleo

Used by injured worker to report their employment history for the past three years and the wages at each job.



Formulario
F242-109-999

Otro(s) idioma(s):
Ingl茅s
 
How to Ride Safely on Elevators, Escalators and Moving Walks
Pamphlet/booklet: Provides safety tips and interesting facts to promote safe use of elevators, escalators and moving walks.

Publicaci贸n
F621-084-000
 
Cholinesterase Monitoring Health Care Provider Recommendations

Filled out by the provider. This form gives the recommendations by the provider of what needs to be done based on the test results on the employee.



Formulario
F413-070-000

Otro(s) idioma(s):
Espa帽ol
Espa帽ol
 
Washington State Prevailing Wage Law

Booklet: Contains the prevailing wage laws (RCWs) and rules (WACs) as well as plain language descriptions and contact information.



Publicaci贸n
F700-032-000
 
Monitoreo de la Colinesterasa - Recomendaciones del Proveedor Médico (Formulario Muestra)

Filled out by the provider. This form gives the recommendations by the provider of what needs to be done based on the test results on the employee.



Formulario
F413-070-999

Otro(s) idioma(s):
Ingl茅s
Ingl茅s
 
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
 
What Are Your Rights when You Work for a Farm Labor Contractor? (English/Spanish) / ¿Cúales son sus derechos cuando trabaja para un contratista de trabajadores agrícolas?

Fact sheet: Provides an overview of rights workers have when they are employed by a farm labor contractor. Several topics are covered, including regular wages, workplace safety, and help if injured on the job.



Publicaci贸n
F700-067-000
 
Physical Therapy / Occupational Therapy Progress Report to Claim Managers

The physical / occupational therapist uses this report to identify the clinical goals and return to work objectives of the injured worker.



Formulario
F245-059-000
 
Registered Apprenticeship Program Address/Mailing Information Update

Used by the Registered Apprenticeship Program to update their address or mailing information. (Note: This DOES NOT update your program standards information.) You should ensure that your address information in the Standards is correct.



Formulario
F100-512-000
 
Equal Employment Opportunity (EEO) Resource & Referral Update Form

Used by an organization to get on the Apprenticeship Program equal opportunity resources list or use to update their information on the list.



Formulario
F100-513-000
 
Log of Good Faith Effort Documentation

This is for Registered Apprenticeship Programs to record Good Faith Effort activities in accordance with their Registered Apprenticeship Standards (Equal Employment Opportunity Plan)



Formulario
F100-515-000
 
Apprenticeship Related Supplemental Instruction (RSI) Plan Review Glossary of Terms
Glossary of terms used with Apprenticeship Related Supplemental Instruction (RSI) Plan Review form and RSI Plan.

Formulario
F100-519-000
 
Seasonal Group Variance Application

Used for Exceptions from the Hours of Work for Minors for Seasonal work. This form is a word document and can be completed electronically. If you have an electronic signature, you may use it on the form. You may save the form and send it as an attachment via email to the address at the top of the form, i.e., teensafety@Lni.wa.gov. If you do not have an electronic signature, complete the form, save it in your files, print it, sign it and fax or mail it to the address at the top of the form. Variance Application forms may be faxed to (360) 902-5300. If you would like the approved Variance Certificate faxed back to your business, please state so on your cover sheet.



Formulario
F700-135-000
 
Apprenticeship Related Supplemental Instruction (RSI) Plan Review

Used by apprenticeship programs/sponsors as part of the process of getting new programs/standards/occupations approved.



Formulario
F100-520-000
 
Apprenticeship Related Supplemental Instruction (RSI) Plan Revew Review Criteria
Describes the process for getting approval of new or revised RSI for new apprenticeship programs/standards/occupations.

Formulario
F100-521-000
 
Hiring Teens this Summer?

Flier: Provides important information about hiring teens, including extra safety precautions, as well as legal requirements regarding minor work endorsement, hours and prohibited duties. Provides telephone, e-mail and Web contacts for more information.



Publicaci贸n
F700-142-000
 
Training Agent Agreement and Understanding of Equal Employment Opportunity (EEO) Requirements of the Apprenticeship Committee - Alternate Selection Process

This should be signed by all employers who are Training Agents with Apprenticeship Programs that use an Alternate Selection Process. This also explains their obligations and rights as part of this process.



Formulario
F100-523-000
 
Washington State Apprenticeship Programs Catalog
Book: Provides an overview of apprenticeship, explains general requirements, lists the apprenticeship programs in Washington State and, and provides contact information. The version available online may contain more up-to-date information than the June 2012 printed edition.

Publicaci贸n
F100-041-000
 
Hiring Teens this Summer? - Spanish (驴Piensa contratar adolescentes este verano?)
Flier: Provides important information about hiring teens, including extra safety precautions, as well as legal requirements regarding minor work endorsement, hours and prohibited duties. Provides telephone, e-mail and Web contacts for more information.

Publicaci贸n
F700-142-999

Otro(s) idioma(s):
Ingl茅s
 
Summary of Agricultural Employment Regulations and Farm Contractor Requirements

This summary is on employment laws relating to the agricultural industry.



Publicaci贸n
F700-124-000
 
Youth in Construction - English/Spanish (Adolescentes en construcción)
Booklet/pamphlet: Explains the limits on work teens under age 18 can perform in the construction industry, discusses the importance of training and emphasizes safety. Includes a checklist of "do's" and "don'ts" for employers, plus other resources.

Publicaci贸n
F700-145-909
 
Agricultural Employer Worksheet

Used by agricultural employers to assist them in determining if they are following the state Agricultural Employment Standards and the Minimum Wage Act for their employees.



Formulario
F700-125-000
 
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.

Publicaci贸n
F262-262-000

Otro(s) idioma(s):
Espa帽ol
 
Preparing for Your Self-Insurance Audit

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



Publicaci贸n
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.

Publicaci贸n
F213-022-000
 
Chemical Hazard Communication: Helpful information for employers
Book: Provides employers a checklist on the requirements of the chemical hazard communication rule. Contains an extensive question-and-answer section and information on starting an employee-training program.

Publicaci贸n
F413-012-000

Otro(s) idioma(s):
涓浗鐨
頃滉淡鞚
Espa帽ol
Vi峄噒
 
Frequently Asked Questions about Job Modifications
Fact sheet: Answers questions employers, workers and doctors may have about job modifications, including when to request a job-modification consultant and who pays for the costs involved.

Publicaci贸n
F245-057-000
 
驴Lesionado por un tercero? Usted tiene opciones legales - English (Injured by a Third Party? You Have Legal Options)
Folleto: Un resumen de los derechos legales y opciones que tiene un trabajador lesionado si una acci贸n contra un tercero est谩 relacionada con su reclamo de compensaci贸n para los trabajadores. Incluye el Formulario de elecci贸n contra terceros que debe ser completado por el trabajador. Aviso. El formulario debe imprimirse, firmarse y enviarse por correo.

Formulario
F249-008-999

Otro(s) idioma(s):
Ingl茅s
 
Quick Tips for Lifting/Consejos Breves para Levantar Cargas (English/Spanish)

Fact sheet: Provides 10 tips for safer lifting. Contains illustrations.



Publicaci贸n
F417-055-909
 
Guidelines for Selecting Reserve Trees
Book: Provides technical guidance on retaining reserve trees in concert with safe work practices and forest and wildlife management goals. Produced cooperatively by state and federal agencies and industry groups.

Publicaci贸n
F417-092-000
 
Workers' Compensation Discrimination-English/Spanish (Discriminación porque se lesionó en su trabajo)
Fact sheet: Explains workers' legal right to file a workplace injury claim and how to file a complaint if discrimination has occurred.

Publicaci贸n
F262-249-909
 
Competent Person Evaluation - Fall Restraint & Fall Arrest

The employer uses this checklist to determine the person they have designated as a competent person is competent within the description and intent of the fall restraint and fall arrest standard.



Formulario
F417-102-000
 
Your Lungs, Your Work, Your Life: What You Should Know about Work-related Asthma

Pamphlet/booklet: Briefly reviews the symptoms and causes of work-related asthma and explains prevention and treatment approaches.



Publicaci贸n
F413-060-000

Otro(s) idioma(s):
褉褍褋褋泻懈泄
Espa帽ol
 
Competent Person Evaluation - Excavation & Trenching

The employer uses this checklist to determine the person they have designated as a competent person is competent within the description and intent of the excavation and trenching standards.



Formulario
F417-104-000
 
Fall Protection Work Plan Requirements

This booklet defines the work plan requirements you must meet for fall protection.



Formulario
F417-107-000
 
Sus Pulmones Su trabajo Su vida: Lo que debería saber acerca del asma ocupacional
Pamphlet/booklet: Briefly reviews the symptoms and causes of work-related asthma and explains prevention and treatment approaches.

Publicaci贸n
F413-060-999

Otro(s) idioma(s):
Ingl茅s
褉褍褋褋泻懈泄
 
Lessons for Lifting & Moving Materials
Book: Identifies work areas, tasks and procedures that place employees at risk of injury. Describes and illustrates methods that help reduce the risk of injury.

Publicaci贸n
F417-129-000
 
Agricultural workers information line (English/Spanish)
Card: Wallet card with a toll-free telephone number where agricultural workers can call to learn about their workplace rights.

Publicaci贸n
F700-103-909
 
Office Ergonomics: Practical solutions for a safer workplace
Book: Provides information and tools to analyze office jobs, find problems and develop ergonomic solutions.

Publicaci贸n
F417-133-000
 
Lumber Handling in Sawmills

Book: Developed by mill workers, mill managers and L&I, this manual describes the risks of musculoskeletal injury in lumber-handling jobs. Identifies controls to reduce hazards,increase efficiency and reduce injuries.



Manual
F417-196-000
 
Stay Clear of Suspended Loads
Pictures a guy under a suspended wooden carton. Get poster printing tips.

Cartel
FSP0-908-000
 
Personal Protective Equipment (PPE) Guide
Book: This guide helps employers comply with the WISHA Personal Protective Equipment rules. It covers general personal protective equipment and PPE requirements used to protect the head, eyes and face, hand and arm, foot and leg, and body (torso) in most work environments.

Publicaci贸n
F417-207-000
 
Fall Protection: Responding to Emergencies
Book: This guide is for employers and for employees who work from exposed, elevated surfaces. It covers the following: what to do to prevent fall-related emergencies and how to respond promptly if a fall-related emergency occurs. Includes illustrations of aided-rescue equipment systems.

Publicaci贸n
F417-208-000
 
Four Steps to Proper Lifting
Pictures of a person lifting a large box correctly along with tips on how to correctly lift a large item safely. Get poster printing tips.

Cartel
FSP0-918-000
 
Protect Yourself and Your Family from Lead Poisoning
Pamphlet/booklet: Explains the risks of lead exposure for workers who work on outdoor steel structures, and harmful effects on workers and their families. It includes a poster about the importance of safe work practices and procedures.

Publicaci贸n
F417-214-000
 
Robberies and Abusive Customers: Tips for Preventing Injuries
Tips on handling cash and how to have a safer restaurant or retail environment. Get poster printing tips.

Cartel
FSP0-919-000
 
Application for Copies of Citation and Notice

Used by an employee to apply for copies of citation and notices issued to their employer.



Formulario
F418-023-000
 
Always Wear Eye Protection
Picture of a large eye with some content on when to use eye protection. Get poster printing tips.

Cartel
FSP0-940-000

Otro(s) idioma(s):
Espa帽ol
 
Ten Safe Handling Hints for Knives
Shows ten tips on handling a knife safely. Get poster printing tips.

Cartel
FSP0-903-000
 
Well...My Daddy Wears 'Em
Little boy wearing his daddy's hard hat, eye protection, gloves and boots. Get poster printing tips.

Cartel
FSP1-010-000
 
2008 Annual Report for the Washington State Fund: Washington's State-run Workers' Compensation Program

Book: Introduces Washington State's Workers' Compensation Program, including rate-setting and investment policies, financial statement overview, and services available to help employers control workers' comp costs.



Publicaci贸n
F101-086-000
 
Watch Where You Step
Large lettering: Watch Where You Step. Get poster printing tips.

Cartel
FSP1-055-000
 
Ten Steps for Avoiding Burns
Tips on how to avoid burns while cooking. Get poster printing tips.

Cartel
FSP0-906-000
 
High Noise Area, Wear Hearing Protection
Cartoon of a guy plugging his ears with his fingers while his hearing protection is wrapped around his neck with the words 'High Noise Area' above his head. Get poster printing tips.

Cartel
FSP1-065-000
 
Preauthorization Request for Services for State Fund Workers' Compensation Patients

This form can only be used for services that can be authorized by the claim manager and it should not be used for Utilization Review (Qualis), Provider Hotline or requests to the Occupational Nurse Consultant.  If you are unsure of what services need to be authorized see L&I fee lookup utility at www.Lni.wa.gov/apps/FeeSchedules/

For complete information on all authorization processes please see:  www.Lni.wa.gov/ClaimsIns/Providers/AuthRef/GetAuth.asp



Formulario
F242-397-000
 
Si usted TIENE que remover este resguardo 5 1/2 x 2 1/8

Sticker: 5.5 inches X 2.15 inches



Calcoman铆a
FSP0-993-991

Otro(s) idioma(s):
Ingl茅s
 
Workers' Compensation Benefits: A Guide for Injured Workers

Pamphlet/booklet: For workers covered by L&I (the State Fund). Describes benefits if you have a work-related injury or illness and how to file a claim. Explains a worker's rights and responsibilities under Washington State's industrial insurance law. Note: Previously titled, Workers' Guide to Industrial Insurance Benefits.



Publicaci贸n
F242-104-000

Otro(s) idioma(s):
Espa帽ol
 
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):
Espa帽ol
 
Independent Contractor Guide: A Step-by-Step Guide to Hiring Independent Contractors in Washington State

Pamphlet/booklet: A step-by-step guide to hiring independent contractors in Washington State. This publication is a general guide to help you understand how and when the Department of Labor & Industries applies workers’ compensation laws to independent contractors.



Publicaci贸n
F101-063-000

Otro(s) idioma(s):
Espa帽ol
 
Address Change Request for Injured Workers - (Spanish) Solicitud para Cambio de Direccion para Trabajadores Lesionados

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
F242-388-999

Otro(s) idioma(s):
Ingl茅s
 
Self-Insurance Certification Questionnaire

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



Formulario
F207-176-000
 
Provider Network Agreement
The provider network agreement for participation in the health care provider network for injured workers covered by Washington State Fund and self-insured employers.

Formulario
F245-397-000
 
Option 2 Vocational Benefits Training Enrollment Application and Verification

State fund workers who have selected Option 2 and closed their claim can use this form to apply for access to their Option 2 training funds. To seek reimbursement, use form F245-030-000 Statement for Retraining and Job Modification Services.



Formulario
F280-024-000

Otro(s) idioma(s):
Ingl茅s/Espa帽ol
 
Option 2 Vocational Benefits Training Enrollment Application/Aplicación y Verificación del Registro (English/Spanish)

State fund workers who have selected Option 2 and closed their claim can use this form to apply for access to their Option 2 training funds. To seek reimbursement, use form F245-030-000 Statement for Retraining and Job Modification Services.



Formulario
F280-024-909

Otro(s) idioma(s):
Ingl茅s
 
General Provider Billing Manual

General billing information for those providers that bill the department.



Manual
F248-100-000
 
Your Lungs, Your Work, Your Life: What You Should Know about Work-related Asthma (Russian)
Pamphlet/booklet: Briefly reviews the symptoms and causes of work-related asthma and explains prevention and treatment approaches.

Publicaci贸n
F413-060-444

Otro(s) idioma(s):
Ingl茅s
Espa帽ol
 





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