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Journey Level Wage Rate from which apprentices' wages rates are computed.

Used to submit the Journey-level wage rate from which the apprentices' wage rate is computed. Form must be submitteed at least annually or sooner if the rates change.



Formulario
F100-050-000
 
Apprenticeship Complaint (Not for Apprenticeship Appeals)

Used to file a complaint on a apprenticeship program, committee, training agent, etc. NOT be used by Apprentices appealing Committee Decisions.



Formulario
F100-505-000
 
Comparing Career Pathways

Fact sheet: Assists high school students and their parents by comparing the benefits of registered apprenticeship to a traditional university or college program. Compares wages, costs, and length of study.



Publicación
F100-531-000
 
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.



Publicación
F101-002-000
 
Agreement of Assumption and Guarantee of Workers' Compensation Liabilities - Application of Certification

Used by an employer to apply for self-insurance.



Formulario
F207-040-000
 
Agreement of Assumption and Guarantee of Workers' Compensation Liabilities (Certified Self-Insurer)

Used by certified self-insured companies when they are acquired by another organization. New parent organization guarantees the self-insured workers' compensation liabilities of its new subsidiary.



Formulario
F207-040-001
 
A Guide to Workers' Compensation Benefits For Employees of Self-Insured Businesses

Pamphlet/booklet: Explains to employees of self-insured businesses their rights and responsibilities under industrial insurance law. Describes benefits and how to file a claim.



Publicación
F207-085-000

Otro(s) idioma(s):
Español
 
Guía de beneficios de Compensación para los Trabajadores: para los empleados de empresas autoaseguradas

Folleto: Explica a los empleados de negocios autoasegurados sus derechos y responsabilidades bajo la ley de seguro industrial.  Describe los beneficios y como  presentar un reclamo.



Publicación
F207-085-999

Otro(s) idioma(s):
Inglés
 
Workers' Compensation Filing Information

Used by only self-insured employers to comply with WAC 296-15-400. The form provides information and instructions to employees of self-insured employers in case of an injury or development of an occupational disease.



Formulario
F207-155-000

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

Usado solamente por los empleadores autoasegurados para cumplir con el Código Administrativo de Washington (WAC, por su sigla en inglés) 296-15-400.  El formulario proporciona información e instrucciones para los empleados de empleadores autoasegurados en caso de una lesión o desarrollo de una enfermedad ocupacional.



Formulario
F207-155-999

Otro(s) idioma(s):
Inglés
 
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
 
Workers' Compensation Employer's Quarterly Report

You must fill out this form quarterly even if you had no workers. These forms are mailed out quarterly to all employers. For instructions on how to complete the Quarterly Report, please refer to F212-239-000 which is available on the internet. This file on the internet is a sample only. Online sample is not available.



Formulario
F212-055-000
 
Workers' Compensation Record Keeping and Reporting Guides

Packet: Contains eight quick reference cards covering topics related to workers' compensation record keeping and reporting. Topics include: computering worker hours, standard exception classifications, excluded employments and corporate officers.



Publicación
F212-222-000
 
Washington Workers Insured Out-of-State: Employer’s Supplemental Quarterly Report for Workers’ Compensation

The purpose of 212-233-000 Supplemental reporting form is to allow employers to report out-of-state wages and hours as per the requirement in WAC 296-17-25203(8).



Formulario
F212-233-000
 
Instructions for completing the Workers' Compensation Employer's Quarterly Report

Instructions for completing the Workers' Compensation Employer's Quarterly Report. A sample of the form F212-055-000 is also available on the internet.



Formulario
F212-239-000
 
QuickFile: Workers' Compensation Quarterly Report Filing Made Easy!

Rack card: Information to help employers file their Workers' compensation quarterly report online. Includes filing webpages links and deadlines.



Publicación
F212-244-000
 
Cancellation of Elective Coverage - Sole Proprietors/Partner, Member of Limited Liability Company (LLC), Member of Limited Liability Partnership (LLP) or For-Profit Corporate Officers

Used by an employer to cancel workers' compensation coverage for Sole Proprietors/Partner, Member of Limited Liability Company (LLC), Member of Limited Liability Partnership (LLP) or For-Profit Corporate Officers.



Formulario
F213-004-000
 
Temporary Services Guide to Workers' Compensation Insurance

Used by L&I to assign industrial insurance classifications for workers of temporary help agencies. The first file is a PDF of the Temporary Services Guide to Workers' Compensation Insurance. The second file is a 2003 Excel file. This file is a cross match of non temporary help classifications and the temporary help risk classification associated with that risk class. The third file is a 2003 Excel file. This is a reverse look up for temporary help risk classification and the non temporary classes associated with a temporary help class. File contains an instructions worksheet for the reverse look up worksheet.



Manual
F213-019-000
 
Student Volunteers and Workers' Compensation Coverage

Fact sheet: Covers availability, limitations and cost of Washington State's optional workers' compensation coverage for student volunteers.



Publicación
F213-023-000
 
Application for Elective Coverage - Sole Proprietor, Partners, For-Profit Corporate Officers, or Member/Managers of Limited Liability Company (LLC)

Used by employers to apply for workers' compensation coverage for non-mandatory employment. Shows a list of categories of employment that are not considered mandatory to have workers' compensation.



Formulario
F213-042-000
 
Workers' Compensation Insurance Manual

This manual covers Chapter 296-17 and 296-17A WAC. Topics covered are employer reporting requirements for workers' compensation; employer classification for workers' compensation; and rates and experience rating rules for workers' compensation.



Manual
F213-178-000
 
Computing Worker Hours

Quick reference card: Shows employers how to figure workers' compensation premiums for different types of employees: hourly employees, salaried employees, commissioned personnel or employees paid for piecework. This information is part of the publication, Workers’ Compensation Record Keeping and Report Guides.



Publicación
F214-014-000
 
Limited Liability Companies (LLC)

Quick reference card: Reviews the requirements for members or managers of limited liability companies to be exempt from workers' compensation (industrial insurance) coverage. This information is part of the publication, Workers’ Compensation Record Keeping and Report Guides.



Publicación
F214-021-000
 
Notice of Completion of Public Works Contract

This is the form used by public agencies to request L&I's approval to release retainage. All contractors are to be listed on the request form with their associated affidavit id number.  Notices received without affidavit id numbers or incomplete information will not be processed and will be returned to the awarding agency. The first EXCEL document is in Office 2007 format. The second file, with the same title, is in Office 2003 format.



Formulario
F215-038-000
 
Your Workers' Compensation Rate Notice - SAMPLE ONLY

Form used to compute Your Workers' Compensation premiums. Page 2 has rate notice definitions. Sample only.



Formulario
F225-004-000
 
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.



Publicación
F242-104-000

Otro(s) idioma(s):
Español
 
Beneficios de compensación para los trabajadores: una guía para los trabajadores lesionados

Folleto: Explica los derechos y responsabilidades de los trabajadores bajo la Ley de Seguro Industrial.  Describe beneficios y cómo presentar un reclamo.  Aviso: El documento fue anteriormnte titulado, Guía de beneficios del seguro industrial para los trabajadores.  



Publicación
F242-104-999

Otro(s) idioma(s):
Inglés
 
Declaración de derechos para viuda(o) bajo el Programa de Compensación y Beneficios para Trabajadores

Usado por una viuda/viudo cuyo cónyuge falleció a causa de una lesión o accidente relacionado con el trabajo.  Este formulario debe completarse, firmarse, notarizarse y devolverse a L&I dentro de 30 días para que los beneficios no sean interrumpidos.



Formulario
F242-173-911

Otro(s) idioma(s):
Inglés
 
Declaración de derechos para padres o tutor bajo el Programa de Compensación y Beneficios para Trabajadores

Usado por un tutor u otra persona que tiene custodia del hijo menor o discapacitado o dependientes de un trabajador fallecido para declarar su  derecho a recibir los beneficios de pensión para aquellos niños/dependientes bajo su cuidado y custodia.



Formulario
F242-173-922

Otro(s) idioma(s):
Inglés
 
Declaración de derechos para dependientes del trabajador fallecido bajo el Programa de Compensación y Beneficios para Trabajadores

Usado por un dependiente de un trabajador cuya muerte estaba relacionada con una lesión o accidente en el trabajo.  Este formulario debe completarse, firmarse, notarizarse y devolverse a L&I dentro de 30 días para que los beneficios no sean interrumpidos.



Formulario
F242-173-933

Otro(s) idioma(s):
Inglés
 
Application for Loss of Earning Power (LEP) - Compensation Medical

Completion of this form is not a guarantee of benefits. Payment of benefits will be decided by your claim manager.



Formulario
F242-208-000

Otro(s) idioma(s):
Inglés/Español
Español
 
Application for Loss of Earning Power Compensation Medical / Solicitud para compensación por reducción de ingresos (médicos) (English/Spanish)

Completion of this form is not a guarantee of benefits. Payment of benefits will be decided by your claim manager.

El hecho de completar este formulario no es una garantía para recibir beneficios.  Los pagos de beneficios lo decidirá su gerente de reclamo.



Formulario
F242-208-909

Otro(s) idioma(s):
Inglés
Español
 
Solicitud para compensación por reducción de ingresos (médico)

El completar este formulario no es una garantía para recibir beneficios.  El pago de beneficios lo decidirá su gerente de reclamo.



Formulario
F242-208-999

Otro(s) idioma(s):
Inglés
Inglés/Español
 
Application for Loss of Earning Power Vocational / Solicitud para compensación por reducción de ingresos (Vocacionales) (English/Spanish)

Completion of this form is not a guarantee of benefits. Payment of benefits will be decided by your claim manager.

El hecho de completar este formulario no es una garantía para recibir beneficios.  Los pagos de beneficios lo decidirá su gerente de reclamo.



Formulario
F242-209-909

Otro(s) idioma(s):
Inglés
Español
 
Solicitud para compensación por reducción de ingresos (Vocacional)

Completando este formulario no es una garantía para recibir beneficios.  El pago de beneficios lo decidirá su gerente de reclamo.



Formulario
F242-209-999

Otro(s) idioma(s):
Inglés
Inglés/Español
 
Pension and Survivor Benefits in Washington State's Workers' Compensation Program / Beneficios de pensión y para sbrevivientes del Programa de compensación para trabajadores de Washington (English/español)

Pamphlet/booket: Answers the most common questions about pension and survivor benefits under Washington's workers' compensation program.

Folleto: Respuestas para las preguntas más comunes sobre pensión y beneficios para sobrevivientes bajo el Programa de compensación para los trabajadores de Washington.



Publicación
F242-352-909
 
Affidavit for Time Loss Compensation Benefits

Completed by injured workers contending eligibility for payment of back time loss benefits for a period that exceeds six months or $25,000. Injured workers requesting benefits for current time missed from work due to a work-related injury should use the F242-052-000 Worker Verification Form.



Formulario
F242-395-000

Otro(s) idioma(s):
Español
 
Declaración firmada para compensación de tiempo perdido

Para ser completada por los trabajadores lesionados que reclaman que tenian derecho a recibir el pago de beneficios de tiempo perdido no pagados anteriormente por un periodo que excede seis meses o $25,000.  Los trabajadores lesionados que soliciten beneficios por el tiempo perdido de trabajo actual debido a una lesión relacionada con el trabajo deben usar el Formulario de verificación de empleo, F242-052-999.



Formulario
F242-395-999

Otro(s) idioma(s):
Inglés
 
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
 
Complete Stay at Work Guide for Employers, The

Booklet: Explains Stay at Work, a financial incentive program that encourages Washington employers to find light-duty or transitional jobs for workers recovering from on-the-job injuries. Provides information on reimbursements, what is covered and how to apply. Detailed Q&A section included.



Publicación
F243-005-000
 
Statement for Compound Prescription

Bill form for use by pharmacies and home infusion companies to submit compound drug charges. This form is for drug charges only and is filled out by the pharmacist.



Formulario
F245-010-000
 
HCFA Proprietary Format Companion Guide
This guide details the HCFA proprietary format structure and provides information regarding electronic billing to the department via Provider Express Billing (PEB).

Formulario
F245-394-000
 
ASC X12N 005010 EDI Transactions Companion Guide
Description: This guide details the HIPAA ASC X12N 005010 format structure for EDI and provides information regarding electronic billing To the department via Provider Express Billing (PEB)

Manual
F245-398-000
 
Pharmacy Companion Guide

This guide details the HIPAA ASC X12N 004010 format structure for 835 Pharmacy Remittance Advice and provides information regarding electronic billing to the department via Provider Express billing (PEB)



Manual
F245-400-000
 
Industrial Insurance Discrimination Complaint

Employees who believe they have been discriminated against by their employer use this form to file a complaint.



Formulario
F262-009-000

Otro(s) idioma(s):
Español
 
Claim Suppression Complaint

An injured worker may submit this form if their employer has suppressed their right to file an injury claim.



Formulario
F262-024-000

Otro(s) idioma(s):
Español
 
Targeting Fraud and Abuse in Washington State's Workers' Compensation Program: 2008 Report to the Legislature
Booklet/Pamphlet: Provides an overview of L&I's activities to deter and detect workers' compensation fraud and abuse by workers, employers and medical providers. Includes statistics on dollars collected and costs avoided.

Publicación
F262-032-000
 
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
 
Targeting Fraud and Abuse in Washington State's Worker's Compensation Program: 2005 Report to the Legislature
Booklet/pamphlet: Provides an overview of L&I's activities to deter and detect workers' compensation fraud and abuse by workers, employers and medical providers. Includes statistics on dollars collected and costs avoided.

Publicación
F262-251-000
 
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
 
Las primas de compensación para trabajadores no pagadas por su subcontratista podrían ser su responsabilidad

Hoja de información: Le informa a los contratistas de construcción cómo protegerse de la responsabilidad por las primas de compensación para los trabajadores no pagadas por su subcontratista.



Publicación
F262-262-999

Otro(s) idioma(s):
Inglés
 
Workers' Comp Fraud Hurts YOU
Pamphlet: Explains the impacts of workers' comp fraud and L&I's efforts to prevent and find fraud by workers, employers, contractors, and medical providers.

Publicación
F262-279-000
 
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):
Español
 
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
 
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.



Checklist
F417-104-000
 
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):
Español
 
Non-Compliance Report - Boiler & Pressure Vessel Inspection

Used by L&I inspectors when a boiler or pressure vessel does not pass inspection. You can only mail or fax this form to L&I. E-mailed forms are NOT accepted.



Formulario
F620-012-000
 
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
 
New/Update Elevator Company Primary Point of Contact

Used by the Elevator Section only to Change and/or Update the Primary Point of Contact for Elevator Companies



Formulario
F621-086-000
 
Lista de comprobación para la preinspección de seguridad contra incendios

Lista de comprobación para dueños de casas sobre cómo mejorar sus casas antes de la preinspección del Departamento de Vivienda y Desarrollo Urbano (HUD, por su sigla en inglés) para alcanzar los estándares en el área de seguridad contra incendios.



Formulario
F622-011-999

Otro(s) idioma(s):
Inglés
 
Contractor Complaint Form

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



Formulario
F625-033-000
 
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
 
Wage Transcription and Computation Sheet

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



Formulario
F700-024-000
 
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
 
Department of Revenue Tax Compliance Certification

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



Formulario
F700-100-000
 
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):
Español
 
Lista de comprobacion para un contratista de trabajores agrícolas

Lista de comprobación para el contratista de trabajadores agrícola para asegurar el cumplimiento.



Formulario
F700-112-999

Otro(s) idioma(s):
Inglés
 
Interested Party Checklist for the Filing of Prevailing Wage Complaints

Checklist used for the filing of Prevailing Wage Complaints by "Interested parties" ONLY.



Formulario
F700-129-000
 
Protected Leave Complaint

For leave from work complaints: Download and complete a Protected Leave Complaint form (F700-144-000)



Formulario
F700-144-000

Otro(s) idioma(s):
Español
 
Electrical Inspection Witness Statement

Used to gather information from a person who was a witness to electrical work that is being investigated by L&I.



Formulario
F500-087-000
 
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):
Español
 
Electrical Program Contacts

Fact Sheet: Provides information for requesting electrical inspections, including telephone numbers and locations of L&I offices that handle electrical inspections.



Publicación
F500-114-000
 
Worker Rights Complaint Form

This is the Worker Rights Complaint Form. Both the 12-2011 and 10-2010 versions are valid.



Formulario
F700-148-000

Otro(s) idioma(s):
Español
 
Green Power Generation System Installation: What You Should Know Before Doing Any Electrical Work
Fact sheet: Explains that an electrical permit and inspection are required for most new, remodel, and maintenance electrical work. Provides information specific to the installation of green power generation systems.

Publicación
F500-116-000
 





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