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Standard Exception Classification

Quick reference card: Provides basic information about standard exception classifications, which can be separately rated from the basic business classification for determining industrial insurance (workers' compensation) premiums. This information is part of the publication, Workers’ Compensation Record Keeping and Report Guides.



Publicación
F214-016-000
 
Audit Reference Card
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.

Publicación
F214-020-000
 
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
 
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
 
Settling your L&I claim might be right for you: A new option for injured workers over 55

Pamphlet/booklet: Explains structured settlement and provides an overview of eligibility and the application and approval processes. The audience for this pamphlet is injured workers who might be eligible.



Publicación
F240-003-000

Otro(s) idioma(s):
Español
 
Settling your injured worker's L&I claim: A new option for injured workers over 55

Pamphlet/booklet: Explains structured settlement and provides an overview of eligibility and the application and approval processes. The audience for this pamphlet is employers covered by the state's workers' compensation program. Self-insured employers should read Publication F240-005-000.



Publicación
F240-004-000
 
Structured Settlement Income and Expense Worksheet

This form is completed by the injured worker, or their representative in conjunction with an Application for Structured Settlement.



Formulario
F240-007-000
 
Request for Manuals from Claims Training

Fillable form to purchase the Workers’ Compensation Adjudicator (WCA), Claims Management (CM), and Policy Manuals (all 3 manuals on 1 CD) the costs will be added up automatically, the total amount enclosed column will be the amount you need to send as payment.



Formulario
F241-021-000
 
Worker Verification Form

Completed by the injured worker if they are unable to work due to a workplace injury AND their employer is not paying their full wages.

 



Formulario
F242-052-000

Otro(s) idioma(s):
Español
 
Claim for Pension by Spouse or Children
Used by a spouse or dependents of a deceased worker. The workers' fatal accident or occupational disease incurred in the course of their employment. This application is needed to determine if applicant(s) is/are entitled to a survivor benefit.

Formulario
F242-056-000

Otro(s) idioma(s):
Español
 
Claim for Pension By Dependents
Used by dependents of a deceased worker to file a claim for benefits.

Formulario
F242-062-000

Otro(s) idioma(s):
Español
 
Occupational Disease & Employment History

Injured worker fills this out to document possible occupational disease and to show work history.



Formulario
F242-071-000

Otro(s) idioma(s):
Español
 
Occupational Disease Work History - Continuation

This is a continuation page to the Occupational Disease Work History (F242-071-000) to add additional work history.



Formulario
F242-071-111

Otro(s) idioma(s):
Español
 
Application to Reopen Claim Due to Worsening Condition

This application is by injured workers and providers to apply to reopen an industrial injury or occupational disease claim due to worsening condition for claims that have been claims 60 days or longer.



Formulario
F242-079-000

Otro(s) idioma(s):
Inglés/Español
Español
 
Application to Reopen Claim due to Worsening Condition / Solictud para volver a abrir un reclamo (English/español)

Used by injured workers and doctors to apply to reopen an industrial injury or occupational disease claim that has been closed for longer than 60 days.

Usado por los trabajadores lesionados y doctores para volver a abrir un reclamo de lesión industrial o enfermedad ocupacional que ha estado cerrado por más de 60 días.



Formulario
F242-079-909

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

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

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



Formulario
F242-109-000

Otro(s) idioma(s):
Español
 
Report of Accident (ROA) Workplace Injury, Accident or Occupational Disease

This form is not available to download. If you are an injured worker, ask your medical provider for a copy of this form or you can complete your portion of the Report of Accident (ROA) online at https://secure.Lni.wa.gov/home.

Please note only medical providers may order this form from the Warehouse.



Formulario
F242-130-000
 
Declaration of Entitlement for Widow or Widower Benefits Under Industrial Insurance
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.

Formulario
F242-173-111

Otro(s) idioma(s):
Español
 
Declaration of Entitlement for Guardian Benefits under Industrial Insurance
Used by a guardian or other person having custody of the minor or disabled children or dependents of a deceased worker to declare their entitlement to receive the pension benefits for those children/dependents in their care and custody.

Formulario
F242-173-222

Otro(s) idioma(s):
Español
 
Declaration of Entitlement for Dependent of Deceased Worker Benefits Under Industrial Insurance

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.



Formulario
F242-173-333

Otro(s) idioma(s):
Español
 
Declaration of Entitlement for Totally Disabled Worker Benefits Under Industrial Insurance
Used by a totally permanently disabled worker. This form must be completed, signed, notarized and returned to L&I within 30 days for non interruption of benefits.

Formulario
F242-173-444

Otro(s) idioma(s):
Español
 
Notice to Employees -- If a Job Injury Occurs/Aviso a los empleados--si ocurre una lesión en el trabajo (English/español)

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.

Cartel requerido:  Describe los pasos que un trabajador debe tomar si le ocurre una lesión o enfermedad relacionada con el trabajo.  También describe brevemente los beneficios disponibles a través del sistema de compensación para los trabajadores de Washington.  Aviso:  Los empleadores que reciben cobertura de seguro industrial de L&I deben colocar este cartel donde los trabajadores puedan verlo.  Las versiones en línea en ingés y español se imprimirán por separado.



Cartel
F242-191-909
 
Notice of Occupational Disease or Infection

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



Formulario
F242-243-000
 
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
 
How to Protest a Department of Labor and Industries Decision / Cómo protestar una decisión en su reclamo del Departamento de Labor e Industrias (English/español)

Fact sheet: Explains how an injured worker can protest decisions on his/her claim and gives deadlines for taking action.

Hoja de información:  Explica como un trabajador lesionado puede protestar las decisiones en su reclamo e indica límites para tomar acción.



Publicación
F242-363-909
 
Insurer Activity Prescription Form (APF)

This form is used by health-care providers to communicate an injured worker's status, physical capacities, inability to work (time-loss) and treatment plans.



Formulario
F242-385-000
 
Address Change Request for Injured Workers
Completed and signed by a State Fund injured worker to notify L&I of a change in address. All address changes must be submitted in writing and signed by the injured worker.

Formulario
F242-388-000

Otro(s) idioma(s):
Español
 
Application for Pension Benefits by Spouse or Children

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



Formulario
F242-391-000

Otro(s) idioma(s):
Español
 
Pension Benefits Questionnaire

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



Formulario
F242-393-000

Otro(s) idioma(s):
Español
 
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
 
FileFast postcard handout for workers
Handout (4.25 x 6): Explains to workers why and how to file an accident report online or by phone following an injury; also reminds them to stay in contact with employer and L&I.

Publicación
F242-398-000
 
FileFast poster for workers
Poster (8.5 x 11): Explains to workers why and how to file an accident report online or by phone following an injury and reminds them to stay in contact with employer and L&I.

Cartel
F242-399-000
 
FileFast wallet card for workers
Wallet card (3.5 x 2): Reminds workers of FileFast web address and number for call center.

Publicación
F242-400-000
 
3 Things to Know about L&I's Medical Provider Network

Handout: Explains to workers the basic information about L&I’s Medical Provider Network. The handout can be used with workers covered both by L&I and by self-insured employers. Applies to workers in Washington state. Includes website and phone number contact information.



Publicación
F242-406-000

Otro(s) idioma(s):
Español
 
Chemical Exposure Questionnaire Packet

Packet that contains:

F242-409-000 Chemical Exposure Questionnaire

F242-410-000 Worker Release for Union Dispatch Records

F262-005-000 Authorization to Release Information

Request for Social Security Earnings Information with the L&I address.



Formulario
F242-409-000

Otro(s) idioma(s):
Español
 
Worker Request for Union Dispatch Records

Worker Request for Union Dispatch Records



Formulario
F242-410-000

Otro(s) idioma(s):
Español
 
Stay at Work Wage Reimbursement Application for Employers

Employer of record can request reimbursement for wages paid to an injured worker during light duty or transitional work. After completing the form, the employer submits it, along with supporting documentation, to the Stay at Work program for review and approval. For expense reimbursements see F243-003-000.



Formulario
F243-001-000
 
Stay at Work Expense Reimbursement Application for Employers Tools, Clothing, Training.

Employer of record can request reimbursement for tools, clothing, or training expenses required to enable an injured worker to return to light duty or transitional work. After completing the form, the employer submits it, along with supporting documentation, to the Stay at Work program for review and approval. For wage reimbursements see F243-001-000.



Formulario
F243-003-000
 
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
 
Stay at Work: A new program to help employers keep injured workers on the job--pays half the wage plus expenses

Pamphlet/booklet: Provides an overview 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. Includes information on eligibility, how to apply, and where to get more information.



Publicación
F243-006-000

Otro(s) idioma(s):
Español
 
Transfer of Care Card

Used by injured worker to notify claim manager and request authorization to transfer care to a different doctor. Do it online! Use the online Transfer of Care



Formulario
F245-037-000

Otro(s) idioma(s):
Español
 
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):
Español
 
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.

Publicación
F245-057-000
 
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
 
Statement for Miscellaneous Services

This bill form is used by providers and injured workers to bill the department for services such as dental care; glasses; medical equipment; nursing home services; interpreter services; services workers pay for out of pocket; and other services. Information on how to bill the department can be found in the General Provider Billing Manual [F248-100-000].

 



Formulario
F245-072-000

Otro(s) idioma(s):
Español
 
Statement for Pharmacy Services

Bill form for prescription charges. May be used by a pharmacy to submit drug charges, or by a worker to request reimbursement for prescriptions paid out of pocket. See the General Provider Billing Manual (F248-100-000) for information on completing this form.



Formulario
F245-100-000
 
CMS 1500 (formerly L&I Health Insurance Claim form)

Used by providers to be reimbursed for services. It is NOT for use by injured workers to submit a claim to L&I.



Formulario
F245-127-000
 
Travel Reimbursement Request

Bill form for use by workers to request reimbursement for authorized travel expenses.



Formulario
F245-145-000

Otro(s) idioma(s):
Español
 
Your Independent Medical Exam

Pamphlet/booklet: Answers the most common questions about independent medical exams and when and why an injured worker may be required to receive one. Includes the "IME Travel & Wage Reimbursement Request" form.



Formulario
F245-224-000

Otro(s) idioma(s):
Español
 
Job Modification Assistance Application

For use by an vocational counselor, employer, etc. to request modification for the injured workers job. This may involve tools and equipment that is purchased through L&I.



Formulario
F245-346-000

Otro(s) idioma(s):
Español
 
Pre-Job Accommodation Assistance Application

For use by a therapist or vocational provider to request job modification for an injured worker before the injured workers is employed, possibly in a retraining program. This may involve tools and equipment that is purchased through L&I.



Formulario
F245-350-000

Otro(s) idioma(s):
Español
 
Vocational Training Plan Ownership Agreement for Tools and Equipment

Injured worker agrees to the ownership terms of the tools and/or equipment purchased as part of their training plan by L&I.



Formulario
F245-351-000

Otro(s) idioma(s):
Español
 
Plan Time Encumbrance
To record the work plan time. For use only with plans approved after 1/1/2008.

Formulario
F245-376-000
 
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
 
Hearing Aid Repair Authorization Fax Request

Hearing Aid Repair Authorization Requests. If you need to purchase or replace a hearing aid, fax all of the information required by Medical Aid Rules and Fee Schedule (MARFS) including the Hearing Services Worker Information (F245-049-000) to 360-902-6252.



Formulario
F245-384-000
 
F245-392-000 Resource Utilization Group (RUG) Residential Care Services for L&I Injured Workers (In place of MDS 3.0 beginning October 1, 2010.)
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.

Formulario
F245-392-000
 
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
 
Washington Practitioner Application

Washington Practitioner Application is used by providers applying for the L&I Provider Network.



Formulario
F245-411-000
 
Interpreter Services for Injured Workers and Crime

Flier: Describes interpreter services available to injured workers and crime victims. Covers how to get an interpreter; who can interpret and get paid for it; and basics of interpreter's professional conduct.



Publicación
F245-412-000

Otro(s) idioma(s):
Español
 
Department of Labor and Industries Home Modification Acknowledgement of Responsibilities

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



Formulario
F247-003-000

Otro(s) idioma(s):
Español
 
Non-Network Provider Application

Includes the F248-036-000 Statewide Payee Registration and W-9 form. For providers to complete that do not want to become a Labor and Industries network provider, or for a specialty that L&I is not accepting network applications for at this time. If you are applying to be a Labor and Industries network provider, please complete application process at www.ProviderNetwork.Lni.wa.gov



Formulario
F248-011-000
 
Electronic Billing Authorization

To authorize L&I to accept electronically submitted bills for services provided to injured workers (2 pages).



Formulario
F248-031-000
 
Out of Country Provider Application

This application is for providers outside the United States. Providers who treat injured workers must have a provider number to bill the department.



Formulario
F248-361-000

Otro(s) idioma(s):
Español
 
Injured by a third party?  

Brochure: Summarizes the legal rights and options an injured worker has if a third-party action pertains to his/her workers' compensation claim. Includes the Third Party Election Form that must be completed by the worker. Note: The form must be printed, signed and mailed.



Formulario
F249-008-000

Otro(s) idioma(s):
Español
 
Application for Inclusion on List of Eligible Attorneys

Used by attorneys to be included on the Workers' Compensation Special Assistant Attorney General Program eligible list for Third Party claims.



Formulario
F249-017-000
 
Is Retrospective Rating Right for You?
Pamphlet: Provides information about L&I's Retrospective Rating Program. In Retro, employers can earn a partial refund of workers' compensation premiums if they reduce workplace injuries and lower associated claim costs.

Publicación
F250-006-000
 
Application for Limited Elective Coverage for Licensed Pony Riders

This form is used to provide free-agents the ability to obtain workers’ compensation insurance benefits.



Formulario
F250-026-000
 
Medical Examiners' Handbook

Book: A publication for independent medical examiners, attending doctors and consultants, this document contains guidelines, sample reports and billing procedures for preparing and conducting impairment ratings and independent medical exams in Washington's workers' compensation system. Beginning July 1, 2012, free Category I CME credits are available for completing the self-assessment associated with this handbook. Go to www.Imes.Lni.wa.gov and click on Medical Examiners Handbook for information on the exam. L&I and the authors have no financial interest or other relationship with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this document. Find a medical examiner.



Publicación
F252-001-000
 
Attending Doctor's Handbook

Note: The October 2012 update edition contains limited new information, including a summary of recent workers' compensation reforms. The inside pages remain the same as the 03-2005 edition. This handbook contains useful information to help providers who treat patients in the workers' compensation system. Physicians can obtain 3 hours of CE credit by completing an online self-assessment based on this handbook. L&I and the authors have no financial interest or other relationship with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this document.



Publicación
F252-004-000
 
Doctor's Worksheet for Rating Dorso-Lumbar & Lumbo-Sacral Impairment

This worksheet is to help the attending physician perform impairment rating on their patients with permanent partial disability of the Dorso-Lumbar or Lumbo-Sacral spine.



Formulario
F252-006-000
 
Medical Device Review Request

This form is so L&I's Office of the Medical Director can evaluate medical device(s) that the attending physican wants to use to treat an injured worker.



Formulario
F252-013-000
 
Vocational Closing Report Routing Sheet

Routing slip that accompanies the Vocational Services Closing Cover Sheet (F252-028-000) which is used to close vocational services to an injured worker.



Formulario
F252-027-000
 
Vocational Services Closing Cover Sheet

Used to close vocational services of an injured worker. This form is attached to Vocational Closing Report Routing Sheets F280-013-000, F280-014-000 or F252-027-000.



Formulario
F252-028-000
 
Assessment Closing Report

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



Formulario
F252-029-000
 
Sample Self-Employment Agreement

Sample of a letter a return to work person would use to assist L&I in determining whether services or funds should be authorized to assist them in becoming self-employed.



Formulario
F252-032-000
 
Employer's Job Description

Used by employer of record to prepare a written job description for a light-duty job, transitional, modified duty job, or alternative job when an injured worker is unable to work due to an industrial injury or occupational disease. The form includes a description of the job tasks, machinery, tools, equipment and personal protective equipment used, and the physical demands of the job. After completing the employer's job description form, the employer gives it to the injured worker's doctor for review and approval.



Formulario
F252-040-000
 
Sample Format for Vocational Testing Report

Used by vocational counselors to test an injuried worker's skills and abilities.



Formulario
F252-051-000
 
Sample Format for Vocational Evaluation Testing Plan

Used by vocational counselors to evaluate the testing plan of the injuried worker.



Formulario
F252-052-000
 
Doctor's Worksheet for Rating Cervical and Cervico-Dorsal Impairment

Doctor's Worksheet for Rating Cervical and Cervico-Dorsal Impairment



Formulario
F252-056-000
 
Home Modification for Workers with Catastrophic Injuries

Fact sheet: Answers questions about the home modification benefit in Washington State's workers' compensation program, who qualifies, what L&I can pay, and where to get more information.



Publicación
F252-060-000
 
Home Modification for Workers with Catastrophic Injuries - Questions and Answers for Contractors

Fact sheet: Answers questions about the home modification benefit in Washington State's workers' compensation program and the bid process for contractors interested in this work.



Publicación
F252-061-000
 
Making the Best Treatment Choice for Your Chronic Low-back Pain
Fact sheet: Reviews the options that an injured worker with low-back pain should consider in determining the best treatment choice.

Publicación
F252-081-000
 
Occupational Disease Employment History Hearing Loss
Used by injured worker who has filed an occupational hearing loss claim to report their employment history and the nature of the noise exposure at each job. F262-013-111 is the continuation sheet.

Formulario
F262-013-000

Otro(s) idioma(s):
Español
 
Occupational Disease Employment History Hearing Loss (Continuation)
Used by injured worker who has filed an occupational hearing loss claim to report their employment history and the nature of the noise exposure at each job. This form is a continuation of form F262-013-000.

Formulario
F262-013-111

Otro(s) idioma(s):
Español
 
Occupational Hearing Loss Questionnaire
Used by injured worker who has filed an occupational hearing loss claim to provide more specific information regarding how the hearing loss occurred. This is requested by the Claim Manager and sent to the Injured Worker.

Formulario
F262-016-000

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
 
Targeting Fraud and Abuse in Washington State's Workers' Compensation Program: 2009 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 for fiscal year 2009.

Publicación
F262-034-000
 
Stop Work Payroll Report

Stop Work Payroll Report



Formulario
F262-043-000
 
Targeting Fraud and Abuse in Washington State's Workers' Compensation Program: 2010 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 for fiscal year 2010.

Publicación
F262-044-000
 
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
 
Targeting Fraud and Abuse in Washington State's Workers Compensation Program: 2006 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
F262-276-000
 
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
 
Targeting Fraud and Abuse in Washington State's Workers' Compensation Program: 2007 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
F262-280-000
 
Intent to Hire Preferred Worker
Used by employers when hiring a preferred worker. This form must be received within 60 days of the hiring and the Preferred Worker Employer's Job Description (F280-022-000) form must be attached.

Formulario
F280-010-000
 
Intent to Hire Preferred Worker with Developmental Disabilities
Used by employers rehiring developmentally disabled workers after an industrial injury. This form requests preferred worker status and shows the physical demands of the work to be performed by the worker. The Preferred Worker Employer's Job Description (F280-022-000) should be attached.

Formulario
F280-011-000
 
Plan Development Recommending Plan Approval Routing Sheet
Routing slip that accompanies the Vocational Services Closing Cover Sheet (F252-028-000) which is used to close vocational services to an injured worker only if you are recommending Plan Approval. For all other closing reports, use Vocational Closing Report Routing Sheet (F252-027-000).

Formulario
F280-013-000
 
Assessing Your Ability to Work: Your Rights and Responsibilities
Booklet: Explains the basics of the assessment phase of vocational services to injured workers. L&I sends this booklet to injured workers when they are referred for assessment services.

Publicación
F280-017-000

Otro(s) idioma(s):
Español
 
Plan Development: What Are My Rights & Responsibilities?
Booklet: Explains the basics of the plan development phase of vocational services to injured workers. L&I send this booklet to injured workers when they are referred for plan development services. The assigned vocational rehabilitation counselor is required to review this booklet with the worker at their initial face-to-face meeting.

Publicación
F280-018-000

Otro(s) idioma(s):
Español
 
Carrying Out Your Vocational Plan: Your Rights and Responsibilities During Plan Implementation
Booklet: Explains the basics of the plan implementation phase of vocational services to injured workers. L&I sends this booklet to injured workers once the vocational plan they submitted is approved. Information about continuing with the vocational plan or selecting Option 2 to decline retraining is included.

Publicación
F280-019-000

Otro(s) idioma(s):
Español
 
Preferred Worker Program

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.



Publicación
F280-021-000

Otro(s) idioma(s):
Español
 
Preferred Worker Employers Job Decsription
Used by the employer to describe the job for the preferred worker. This form is reviewed by a vocational services consultant to ensure that the offered job is consistent with the worker's medical restrictions.

Formulario
F280-022-000
 
Request for Preferred Workers Status

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



Formulario
F280-023-000
 
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):
Inglés/Español
 
Option 2 Vocational Benefits Training Enrollment Application/Solicitud y verificación del registro para capacitación de beneficios vocacionales opción 2 (English/español)

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.

Los trabajadores bajo el Fondo estatal que han escogido la Opción 2 y que cerraron su reclamo pueden utilizar este formulario para solicitar acceso de los fondos de capacitación de la Opción 2.  Para solicitar un reembolso, utilice el formulario F245-030-999 Declaración de servicios de capacitación y servicios de modificación de trabajo.



Formulario
F280-024-909

Otro(s) idioma(s):
Inglés
 
On the Job Training Accountability Agreement

This form is for OJT training plans, and must be signed by the worker and VRC then sent in along with your training plan to L&I for approval. For non-OJT retraining plans, please refer to form F280-016-000.



Formulario
F280-029-000

Otro(s) idioma(s):
Español
 
Are You an Employer Who Can Provide On-the-Job Training?
Fact sheet: Explains how employers play an important role in helping injured or ill workers return to meaningful employment and a productive life by offering on-the-job training opportunities.

Publicación
F280-033-000
 
Vocational Questionnaire/Work History

Vocational Questionnaire/Work History for use by Vocational Providers serving injured workers.



Formulario
F280-038-000

Otro(s) idioma(s):
Español
 
Non-accredited or Unlicensed Training Provider Application Supplemental Requirements

Used by non-accredited or unlicensed training providers in order to be reviewed for approval to become a training provider for Washington injured workers. Must be submitted with the Provider Account Application (F248-011-000).



Formulario
F280-045-000
 
Referral  to L&I/WorkSource Partnership Services

Used by private Vocational Providers to refer injured workers to WorkSource



Formulario
F280-046-000
 
Preferred Worker Benefit Frequently Asked Questions

Fact sheet: Includes information regarding the benefits of Preferred Worker certification, answers to questions frequently asked by workers, phone and website contacts.



Publicación
F280-052-000

Otro(s) idioma(s):
Español
 
Workers' Guide to Hazardous Chemicals / Guía del trabajador para el uso de químicos (English/español)

Brochure: Explains workers' rights under Washington's Hazard Communication rule but does not fulfill an employer's legal obligation to provide information and training to employees.

Includes information for workers about working safety around hazardous chemicals and understanding warning labels.

Folleto:  Explica los derechos de los trabajadores bajo la ley de comunicación de riesgos químicos en el estado de Washington pero no satisface la obligación legal del empleador para proporcionar información y capacitación para los empleados.

Incluye información para los trabajadores sobre la seguridad al trabajar donde se usan químicos peligrosos y entender las etiquetas de advertencia.

The Spanish section of this publication is being revised and will be available in the future. / Estamos actualizando la sección en español de esta publicación y estará disponible en el futuro.



Publicación
F413-014-909
 
Poison Oak Poster / Cartel sobre el zumaque venenoso (English/español)

Full-color photographs of poison oak in different seasons help workers recognize and avoid the plant when working outdoors. Note: Poster will split over two pages if printed on 8.5" X 11" paper. Get poster printing tips.

Fotografías del zumaque venenoso a todo color en diferentes estaciones que ayudan a los trabajadores a reconocer y evitar contacto con la planta al trabajar al aire libre.  Aviso:  El cartel se dividirá en dos páginas si se imprime en papel de 8.5 x 11 pulgadas. Obtenga información sobre cómo imprimir carteles.



Cartel
F413-045-000
 
Protecting Yourself and Your Workers from Poison Oak and Ivy /Protejase usted mismo y a sus trabajadores contra el Zumaque Venenoso y la hiebra venenosa (English/Spanish)

Pamphlet/booklet: Discusses the effects of poison oak and ivy, where it is found in Washington State, how to control growth and protect workers from exposure.

Panfleto:  Discute los efectos del zumaque y la hiedra venenosos, dónde se encuentran en el estado de Washington, cómo controlar el crecimiento y proteger a los trabajadores contra la exposición a las mismas.



Publicación
F413-047-000
 
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.



Publicación
F413-060-000

Otro(s) idioma(s):
русский
Español
 
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.

Publicación
F413-060-444

Otro(s) idioma(s):
Inglés
Español
 
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
 
Worker and Community Right-to-Know Program
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.

Publicación
F413-075-000
 
Safety Standards for WAC 296-78- Sawmillis & Woodworking Operations

The Department of Labor and Industries has rewritten and reorganized for clarity and ease of use, Chapter 296-78 WAC, Sawmills and Woodworking Operations.



Manual
F414-010-000
 
Safety Standards for WAC 296-32, Telecommunications

Rules for employees working with telecommunication systems



Manual
F414-017-000
 
Safety Standards for WAC 296-45  -  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
 
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
 
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
 
Safety Standards for WAC 296-24 - 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
 
Safety Standards for WAC 296-62, General Occup Health

The rules in this chapter are designed to protect the health of employees and help to create a healthy workplace by establishing requirements to control health hazards. Requirements for chemical hazard communication programs, workplace lighting levels and exposure records are in chapter 296-800 WAC, the safety and health core rules.



Manual
F414-042-000
 
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
 
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
 
Workplace Safety and Health Rules and Guides

This CD has been discontinued, but the safety and health rules and guides are available on the L&I website.

For more information, see the links in the "Websites" section below.

These links contain all workplace safety and health rules for Washington State and policies and related laws. Included are guides covering accident prevention programs (APP) and personal protective equipment (PPE).

 



CD
F414-074-034
 
Safety Standards for WAC 296-841, Airborne Contaminants

Applies to any workplace with potential or actual employee exposure to respiratory hazards



Manual
F414-118-000
 
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 WAC 296-811, Fire Brigades

Applies to any workplace that chooses to establish a fire brigade.



Manual
F414-134-000
 
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
 
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.



Publicación
F416-036-000
 
Mobile Cranes/Derricks Worksheet for Construction Industry

Mobile Cranes/Derricks Worksheet for Construction Industry



Formulario
F416-043-000
 
Job Safety and Health Law / Ley de Seguridad y Salud en el Trabajo (English/español)

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 Requerido:  Describe partes importantes sobre la Ley de Salud y Seguridad Industrial (WISHA, por su sigla en inglés), la cual proporciona seguridad y salud en el trabajo para los empleados de Washington.  Aviso:  Los empleadores en el estado de Washington deben colocar este cartel donde los trabajadores puedan verlo.  Al ordenar la versión impresa, usted recibirá un cartel de 22 x 17 pulgadas que incluye ambos idiomas.

 Por favor solicítelo de L&I o imprímalo en un papel de 11"x 17".



Cartel
F416-081-909
 
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



Publicación
F416-132-000

Otro(s) idioma(s):
Español
 
Overhead Crane Bridge, Monorail, Gantry Worksheet for Construction
Overhead Crane Bridge, Monorail, Gantry Worksheet for Construction.

Formulario
F416-141-000
 
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
 
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.

Publicación
F417-092-000
 
Fall Protection Work Plan Requirements

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



Formulario
F417-107-000
 
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.

Publicación
F417-129-000
 
Workplace Violence: Awareness and Prevention for Employers and Employees
Book: Describes four types of workplace violence, outlines steps to minimize and prevent violent acts, and discusses potential risk factors and prevention techniques.

Publicación
F417-140-000
 
Safety and Health Discrimination in the Workplace / Discriminación de seguridad y salud en el lugar de trabajo (English/español)

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:  Los empleadores tienen derecho a reportar las inquietudes relacionadas con la seguridad y la salud en el lugar de trabajo.  Este cartel describe  las "actividades protegidas" bajo la Ley de Salud y Seguridad Industrial de Washington (WISHA, por su sigla en inglés) y explica lo que debe hacer un empleado si él/ella ha sido castigado o despedido por ejercer sus derechos.  Obtenga consejos para imprimir carteles.



Cartel
F417-188-909
 
Pocket Guide to Caution Zone Jobs

Pamphlet/booklet: This advisory pocket guide reviews 14 workplace risk factors that can lead to soft tissue injuries such as back strain, tendinitis and carpal tunnel syndrome. Suggests ways to identify the risk factors. Lists helpful resources from L&I.



Publicación
F417-195-000
 
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
 
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.

Publicación
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.

Publicación
F417-208-000
 
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.

Publicación
F417-210-000
 
Jorge's New Job: Cholinesterase Testing in Washington State / 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.

Panfleto/folleto:  Utiliza un formato de cuento con diálogo y fotografías para explicar los peligros de la colinesterasa, el programa de monitoreo del estado y la importancia del uso adecuado del equipo de seguridad cuando se trabaja con pesticidas.



Publicación
F417-213-909
 
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.

Publicación
F417-214-000
 
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.



Publicación
F417-224-000
 
Safety and Health Program Assessment Worksheet

Safety and Health Program Assessment Worksheet



Formulario
F417-227-000
 
Ergonomics Consultation: Free, Confidential, Powerful Impact on Your Bottom Line

Pamphlet: Provides information to employers interested in a free ergonomics consultation for their business. Explains the importance of workplace ergonomics and how L&I can help to assess injury-causing tasks, and help develop an ergonomics program.



Publicación
F417-233-000
 
Q&A: Stay of Abatement Date

Fact sheet: Explains how an employer requests a "stay of abatement date." Effective July 1, 2012, an employer must fix a hazard cited in a workplace inspection during appeal unless he or she has requested and been granted a stay of abatement date.



Publicación
F417-235-000
 
When a Loved One Dies at Work

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.



Publicación
F417-240-000

Otro(s) idioma(s):
Español
 
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.



Publicación
F417-241-000
 
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.



Publicación
F417-244-000

Otro(s) idioma(s):
Español
 
Risk Management Consultation

Pamphlet/booklet: Describes the benefits of free risk management consultations. L&I’s Risk Managers can provide: data and analysis specific to your business that shows how claims can affect the premiums you pay; show you the cost/benefit of claim management strategies; identify return-to-work options and resources; and review best practices in hiring strategies and procedures.



Publicación
F417-246-000
 
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.



Publicación
F417-248-000
 
Fall Hazards: Standing Walls - Highlights of Fall Protection Requirements

Safety Topic fact sheet: Describes the fall hazards workers are exposed to while framing, erecting and raising walls without using fall protection. Includes photos, safety requirements and different methods of fall restraints and fall arrest systems.



Publicación
F417-252-000
 
Hazard Documentation Worksheet

Hazard Documentation Worksheet for use by L&I compliance staff to describe, measure and comment on workplace hazards.



Formulario
F418-031-000
 
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
 
Application to Access L&I's Electrical Permit and Inspection System (EPIS) from SecureAccess Washington and Utilize Contractor Deposit Account via the Internet

To establish a contractor deposit account by an electrical contactor or registered construction contractors who are legally required to purchase electrical work permits from L&I.



Formulario
F500-055-000
 
Investigation Report

To notify L&I on any electrical work that you think is illegal.



Formulario
F500-076-000
 
Electrical Work on Residential Property: What You Should Know Before Work Begins
Fact Sheet: Explains to property owners the importance of electrical permits, inspections and approvals. An electrical permit is required for most new, remodel and maintenance electrical work.

Publicación
F500-078-000
 
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
 
Electrical Work on Commercial Property: What You Should Know Before Work Begins
Fact Sheet: Explains to commercial property owners the importance of electrical permits, inspections and approvals. An electrical permit is required for most new, remodel and maintenance electrical work.

Publicación
F500-109-000
 
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.

Publicación
F500-110-000
 
Before Electrical Sign Work Begins: What Electrical Sign Contractors and Electricians Should Know
Fact Sheet: Explains work that is allowed and not allowed under (04) Sign Scope of Work and what electrical sign contractors and electricians should know before doing sign work. Also covers electrical Class B labels and electrical permits, inspections and fees.

Publicación
F500-111-000
 
Class B Labels: What You Should Know

Fact Sheet: Explains Class B label electrical work, scope and limitations, and provides general instructions for using Class B labels.



Publicación
F500-112-000
 
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.

Publicación
F500-115-000
 
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
 
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
 
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.

Publicación
F621-070-000
 
Permit Refund Request

A form to request a refund for an electrical work permit, elevator permit, or factory-assembled structure alteration permit.



Formulario
F621-105-000
 
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
 
Hiring a Plumber? Hire Smart!

Worksheet: Provides advice and step-by-step hiring tips for homeowners planning a remodel, repair or addition to their home that involves plumbing. Tells homeowners how to verify that a construction contractor is registered and a plumber is certified with the state.



Publicación
F627-044-000
 
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
 
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
 
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.



Publicación
F700-022-000

Otro(s) idioma(s):
Español
 
Wage Transcription and Computation Sheet

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



Formulario
F700-024-000
 
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
 
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):
Español
 
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
 
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.



Publicación
F700-067-000
 
What Are Your Rights When You Work for a Farm Labor Contractor? / ¿Cúales son sus derechos cuando trabaja para un contratista de trabajadores agrícolas? (English/español)

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.

Hoja de información:  Explica los derechos de los trabajadores cuando están empleados por un contratista agrícola.  Los temas cubiertos incluyen seguridad en el lugar de trabajo, descanso y períodos de comida y ayuda si se lesionan en el trabajo.



Publicación
F700-067-909
 
Your Rights as a Worker in Washington State/ Sus derechos como trabajador en el estado de Washington (English/español)

Required poster: Reviews workers' rights under Washington's wage-and-hour laws. Topics include minimum wage, overtime, meal and rest breaks, pay periods, deductions, and employment of teens under age 18. Also reviews family leave provisions under federal and state law, and leave for spouses of deploying military personnel and victims of domestic violence. Note: Employers in both agricultural and non-agricultural industries in Washington State must display this poster where workers can see it.

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

Get poster printing tips.

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

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

Obtenga consejos para imprimir carteles. 

 

 

 



Cartel
F700-074-909
 
Washington State OverTime Law

Covers compensation for employees in Washington State working overime.



Publicación
F700-079-000
 
Young Workers in Agriculture / Trabajadores jóvenes en la agricultura (English/español)

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.

Folleto:  Contesta muchas de las preguntas que tienen los empleadores y los trabajadores menores de edad sobre el empleo de menores.  Cubre las leyes de trabajo en la agricultura, incluyendo los permisos necesarios, horas y condiciones de trabajo para los trabajadores de 12-17 años de edad.



Publicación
F700-096-909
 
Your Daily Record of Hours Worked / Su registro de horas trabajadas (English/español)

Pamphlet/booklet: A pocket-sized bilingual booklet to encourage workers to keep track of their daily work hours and earnings.

Folleto: Un librito bilingüe de tamaño bolsillo para animar a los trabajadores a mantener un registro de sus horas de trabajo diarias y de sus ingresos.



Publicación
F700-105-909
 
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
 
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
 
Sports Teams and Youth Workers

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



Publicación
F700-130-000
 
Seasonal Group Variance Application

Used for Exceptions from the Hours of Work for Minors for Seasonal work.  Complete the form, 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
 
Congratulations! You've been approved to hire minors
Card: Reminds employers of special work rules for employees under age 18. Lists key points and provides a Web address for where to find more detailed information. Sent to all employers who obtain a minor work permit endorsement on the master business license.

Publicación
F700-136-000
 
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.

Publicación
F700-139-000
 
Hiring teens? / ¿Piensa contratar adolescentes? (English/español)

Fact sheet: 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.

Hoja de información:  Proporciona información importante sobre la contratación de adolescentes, incluyendo precauciones adicionales de seguridad, así como también los requisitos legales referentes al endoso de trabajo para menores, horas y tareas prohibidas.  Proporciona un teléfono, correo electrónico y contactos en la página Web para más información.

 



Publicación
F700-142-909
 
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
 
Minimum Wage Law Exemptions

Covers exemptions to Washington state minimum wage law.



Publicación
F700-051-000
 
Youth in Construction / Adolescentes en construcción  (English/español)

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.

Pamfleto:  Explica los límites en los trabajos que los adolescentes menores de 18 años de edad pueden desempeñar en la industria de la construcción, discute la importancia de la capacitación y enfatiza la seguridad.  Incluye una lista para empleadores de lo que los adolescentes pueden y no pueden hacer además de otros recursos.



Publicación
F700-145-909
 
Minimum Wage Law - Truck Drivers

Record keeping provisions and overtime for truck & bus drivers.



Publicación
F700-095-000
 
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
 
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
 
Pocket Guide to Worker Rights

Brochure: This guide is to help workers understand their rights in Washington State. It includes information about safety and health protection, minimum wage and overtime pay, prevailing wage, rest and meal breaks, sick leave, family leave, workers' compensation benefits and retaliation.



Publicación
F101-165-000
 
Wage-and-Hour Questions Employers Often Ask

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.



Publicación
F700-150-000
 
What You Need to Know if You Don't Get Paid: A Worker's Guide to the Washington State Wage Payment Act / Lo que necesita saber si no recibe su pago: una guía para el trabajador de la ley del pago de salario del estado de Washington (English/español)

Fact sheet: Summarizes workers' rights and responsibilities regarding minimum wage, pay, work hours and overtime and explains how to file a wage complaint. Includes answers to several commonly asked questions.

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



Publicación
F700-153-909
 
Avoid Liability for Your Farm Labor Contractor's Unpaid Debits / Evite su obligación por las deudas no pagadas de su contratista de trabajadores agrícolas (English/español)

Fact sheet: Explains how employers could be liable for unpaid workers' compensation premiums, unpaid wages, damages and civil penalties when hiring a farm labor contractor. Outlines ways to protect against potential liability.

Hoja de información:  Explica cómo los empleadores pueden ser responsables por las primas de compensación para los trabajadores, salarios no pagados, daños y multas civiles al contratar un contratista agrícola.  Indica maneras para protegerse contra una posible responsabilidad.

 



Publicación
F700-154-909
 
Affidavit of Wages Paid EHB 2805 Addendum

F700-164-000 is an addendum to your Affidavit of Wages Paid Form. RCW 39.04.370 requires you to complete form F700-164-000 if the prime contract is at a cost of over one million dollars ($1,000,000). If you fail to properly provide the requested information more than one time between September 1, 2010 and December 31, 2013, pursuant to RCW 39.04.350(1)(f) you will not be considered a responsible bidder qualified to be awarded a public works project. Use as many of these forms as you need in order to provide the requested information for all relevant project items. This is an addendum to form F700-007-000.



Formulario
F700-164-000
 
Student Learner Variance Application

Employer uses this application form for requesting a variance to employment regulations for minors enrolled in a work-based learning placement. It can be used for individual or multiple minors for the same employer.



Formulario
F700-166-000
 
Employing teens under 18 in food service? - L&I’s fact sheet of permitted and prohibited work activities for youth ages 14 to 17 in food service

Fact sheet: Explains permitted and prohibited work activities for youth ages 14 to 17 in food service. Includes rules for driving, student-learner exemptions and work hours.



Publicación
F700-167-000
 
Parent Authorization Summer Work

This form is for summer employment of minors, only, and is for parents or legal guardians to approve the hours and work activities for a minor employee to work according to terms listed by the employer.  All parties must sign to approve the work schedule and duties for a minor prior to permitting them to work.  This is NOT a work permit.  Employers must obtain a minor work permit endorsement on their Business License where they employ workers under 18.



Formulario
F700-168-000
 
Your Daily Record of Hours and Units Worked - For Agricultural Workers / Su registro diario de horas y unidades trabajadas - para trabajadores agrícolas (English/español)

Booklet: A pocket-sized bilingual guide to encourage agricultural workers to keep track of their daily work hours, units and earnings.

Folleto: Una guía de bolsillo bilingüe para animar a los trabajadores agrícolas a mantener un registro de sus horas de trabajo diarias, unidades e ingresos.



Publicación
F700-169-909
 
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
 
How To Calculate Your Wage in Agriculture

Fact/Information sheet: Shows piece rate workers how to calculate their wages to check if they are being paid minimum wage.



Publicación
F700-171-000

Otro(s) idioma(s):
Español
 
Unpaid Internships 101

Fact sheet: Document provides information as the state and federal restrictions for unpaid interns who are in an educational capacity in a workplace.



Publicación
F700-173-000
 
Application for Benefits - Crime Victims

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

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



Formulario
F800-042-000
 
Always Wear Eye Protection

Sticker: 7.25 inches x 4.25 inches.

This sticker is to remind workers to wear eye protection when grinding, milling, sanding, sawing, welding, chipping, chiseling, etc.



Calcomanía
FSP0-941-000
 
Record Keeping Provisions - Employment Standards

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



Formulario
F700-009-000
 
Put this Guard Back - 8.5 x 3.5 inches

This sticker is for employers to place on their equipment to inform workers that if they must remove the guard for service or maintenance to be sure to put it back immediately.



Calcomanía
FSP0-993-000

Otro(s) idioma(s):
Español
 
Grinding Wheel - Prevent Accidents

Sticker: 4 inches x 3 inches.

This sticker is required for grinder wheel equipment. This sticker reminds workers of the maximum distance between the grinding wheel and tongue guard and the maximum distance between the grinding wheel and the work rest.



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

Cartel
FSP1-012-000

Otro(s) idioma(s):
Español
 





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