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.

Affidavit_for_Time_Loss_Compensation_Benefits (Spanish) Declaración Firmada para Compensación de Tiempo Perdido 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 F242-052-999 Worker Verification Form.

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.

Used by a dependent of a worker whose death was related to an on the job injury or accident. This form must be completed, signed, notarized and returned to L&I within 30 days for non interruption of benefits.

Used by the widow/widower whose spouse died of a work related injury or accident. This form must be completed, signed, notarized and returned to L&I within 30 days for non interruption of your benefits.

Identifies the effects of heat exhaustion and heat stroke on the body and what to do if you observe symptoms. Reviews prevention steps. PDF file is set up for two copies to print at one time.

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

Required poster: Outlines the steps a worker should take if a job-related injury or illness occurs. Also briefly describes the benefits available through Washington's workers' compensation system. Note: 'Employers who receive industrial insurance coverage from L&I must display this poster where workers can see it. English and Spanish online versions will print separately. Get poster printing tips.

Required poster for self-insured businesses: Outlines what a worker employed by a self-insured business should do if a work-related injury or illness occurs. Note: Self-insured employers must display this poster where workers can see it. Get poster printing tips.

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

Pamphlet/booklet: Describes the Preferred Worker Program and the benefits employers receive when hiring a preferred workers. In general, these are workers whose work-related injury or occupational disease prevents them from returning to their old job.

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

Used to track apprentices/trainees on-the-job training hours.

Used by Apprenticeship programs to submit related instruction hours to L&I Apprenticeship section. It is preferred that programs use the combined RSI/OJT reporting form. RSI Hours must be reported quarterly.

Used by only self-insured employers and their representatives to calculate and report injured workers’ wages and time loss compensation rates.

Use this form to submit your taxpayer ID number. Note: Register now for direct deposit available at a later date.

Used by third party attorneys to calculate distribution of proposed settlements in third party claims.

Brochure: Provides information to loved ones of workers who died from a job-related injury or illness, including how to apply for survivor benefits. Explains the L&I fatality investigation and how family members can stay informed of the investigation's status.

Copies of the 05-2008 version will be available in the warehouse later in July.

Used by a self-insured employer to change items on the surety document such as amount of letter of credit issued as collateral.

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.

Worksheets used to record the number of hours worked and Related Supplemental Instruction hours during a registered apprenticeship on a monthly basis. If used, a copy is usually given to the program monthly.

Describes the process for getting approval of new or revised RSI for new apprenticeship programs/standards/occupations.

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

Glossary of terms used with Apprenticeship Related Supplemental Instruction (RSI) Plan Review form and RSI Plan.

Used by a self-insured employer as an option to provide collateral for a total permanent disability claim.

Quick reference card: Answers questions employers may have about audits L&I conducts to verify the that workers' hours have been reported correctly and workers' compensation premiums have been calculated accurately.

Used by a dependent of a worker whose death was related to an on the job injury or accident. This form must be completed, signed, notarized and returned to L&I within 30 days for non interruption of benefits.

Used by the widow/widower whose spouse died of a work related injury or accident. This form must be completed, signed, notarized and returned to L&I within 30 days for non interruption of your benefits.

Quick reference guide: Used by drywall contractors to get answers to questions about being a drywall contractor and how it relates to L&I.

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

Application to become an instructor for elevator related courses.

Filled out by the provider when they treat an injured worker. See web links below for: Latest payment amounts, Updates and corrections, and Review payment policy. For use in place of Minimum Data Set (MDS) 3.0 beginning October 1, 2010.

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.

Template used by a doctor during an independent medical exam.

This form must be submitted to L&I's Apprenticeship Section by the Instructor at the time of the incident and the appropriate Apprenticeship Program within 5 days of an accident/incident of an apprentice/trainee during Related Supplemental Instruction (RSI).

Used by a self-insurer to provide collateral for its program only if it has a net worth in excess of $500 million.

Used by a self-insured employer to signify the employer's obligation and responsibilities in conjunction with providing an annuity as collateral for a total permanent disability claim.

Notice of Independent Medical Exam No-Show or Late Cancellation

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

Pamphlet/booklet: Describes the Preferred Worker Program and the benefits employers receive when hiring a preferred workers. Iin general, these are workers whose work-related injury or occupational disease prevents them from returning to their old job.

Used to provide collateral for a self-insured program.

Used by self-insured employers as an option to provide collateral for a permanent total disability claim.

Used by a self-insured employer to amend or change items on the surety document such as the amount of the escrow agreement used as collateral.

Used by self-insured employer as a means to provide surety. This is an agreement between the self-insurer and the bank to hold these securities in trust as collateral for its self-insured program.

This form is predominately used in non-accident related types of inspections. Used to obtain statements from employees or other individuals whenever it is determined that it would be useful to adequately document an apparent violation.

Bill form for providers that bill the department for claim-related retraining and job modification services. See the Retraining and Job Modification Billing Instructions (F248-015-000) for information on completing this form.

Used by a self-insured employer to amend or change items on the surety document such as the amount of a surety bond used as collateral.

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

Fact sheet: Provides answers to questions related to pay requirements, deductions from pay, hiring a teen worker, employee uniforms and access to personnel file. Includes contact information if an employer needs assistance with a specific situation.

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.

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.

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.

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.

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.

Brochure: Provides information to loved ones of workers who died from a job-related injury or illness, including how to apply for survivor benefits. Explains the L&I fatality investigation and how family members can stay informed of the investigation's status.

Fact sheet: Provides an overview of the Worker and Community Right-to-Know (RTK) Program authorized by legislation in 1986. Explains the RTK fees, education on hazardous substances that the fees support, who pays the fees and how they are calculated.

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.

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.

Fact Sheet: Provides answers to commonly asked questions about independent medical exams (IMEs) and contact information. Includes a form for requesting travel-related reimbursement for attending an IME.

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

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