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Master Business Application

Link is to the Master Business License online form: Required for employers who hire minors and is obtained by completing the Master Business Application. Also available from L&I warehouse.



Formulario
BLSF-700-028
 
Program Equal Employment Opportunity Activity Documentation

Used to record individual equal employment opportunity activities conducted by Apprenticeship Programs.



Formulario
F100-012-000
 
The Apprenticeship Advantage: Earn While You Learn!
Fact sheet: Introduces apprenticeship to younger people. Explains the benefits of apprenticeship, a program of study where apprentices earn wages while learning a skilled profession. Includes contact information for L&I's apprenticeship coordinators around the state.

Publicación
F100-022-000
 
Application for Apprenticeship

EXAMPLE ONLY: Example of an application to apply for an apprenticeship. Registered Apprenticeship Programs use their own forms. NOT TO BE USED TO REQUEST PLUMBER or ELECTRICAL TRAINEE CARD.



Formulario
F100-033-000
 
Washington State Apprenticeship Programs Catalog
Book: Provides an overview of apprenticeship, explains general requirements, lists the apprenticeship programs in Washington State and, and provides contact information. The version available online may contain more up-to-date information than the June 2012 printed edition.

Publicación
F100-041-000
 
Apprenticeship Applicant Register
Example: Used for tracking applicants for an apprenticeship program. Registered Apprenticeship Programs use their own forms.

Formulario
F100-045-000
 
Request for Approval of Proposed Standards
Request for new apprenticeship standards.

Formulario
F100-049-000
 
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
 
Related Supplemental Instruction 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.



Formulario
F100-228-000
 
Request for Cancellation of Program
Used for cancelling an apprenticeship program.

Formulario
F100-303-000
 
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
 
Request for Cancellation of New Apprenticeship Committee
To request a cancellation of a new apprenticeship committee which never has a "Request for New Standards" approved by the WSATC

Formulario
F100-510-000
 
Registered Apprenticeship Program Address/Mailing Information Update

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



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

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



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

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



Formulario
F100-515-000
 
Related Supplemental Instruction / On-the-Job Training Hours

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



Formulario
F100-518-000
 
Apprenticeship Related Supplemental Instruction (RSI) Plan Review Glossary of Terms
Glossary of terms used with Apprenticeship Related Supplemental Instruction (RSI) Plan Review form and RSI Plan.

Formulario
F100-519-000
 
Apprenticeship Related Supplemental Instruction (RSI) Plan Review

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



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

Formulario
F100-521-000
 
Training Agent Agreement and Understanding of Equal Employment Opportunity (EEO) Requirements of the Apprenticeship Committee - Alternate Selection Process

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



Formulario
F100-523-000
 
Apprenticeship Committee Representative Qualification Information Experience & Education History

Supplys the experience and education history of new committee members to ensure that they are qualified to be committee members. Used for New Standard submissions only.



Formulario
F100-528-000
 
Using Apprentices on Public Works and Other Projects
Pamphlet: Provides a quick overview of the rules for using apprentices on public works projects, including apprentice utilization. Also describes the benefits of apprenticeship and where to get more information.

Publicación
F100-529-000
 
Apprenticeships For Tribal Members

 

Brochure: Designed for tribal members, this brochure provides an overview of apprenticeship. Topics include the benefits of apprenticeship, career options, how to apply and contact information.

 



Publicación
F100-532-000
 
Access Authorization for External Access to Apprenticeship Registration and Tracking System (ARTS)

Form must be filled out to request access to Apprenticeship Registration and Tracking System (ARTS).



Formulario
F100-535-000
 
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
 
Request for Public Records

To request public records from Washington State Dept. of Labor and Industries. You can order an earlier version from the LNI warehouse until stock is exhausted.



Formulario
F101-009-000
 
Authorization to Release Claim Information

Used by the worker to designate a person(s) as an authorized representative for the worker's claim. An authorized representative can access claim information.



Formulario
F101-010-000

Otro(s) idioma(s):
Español
 
Request for Claim Information

Used by workers, workers' representatives, employers or employers' representatives to request claim information from L&I.



Formulario
F101-010-111
 
Autorización para proveer información de reclamos

Usado por el trabajador para designar a una persona(s) como representante(s) autorizado(s) del reclamo del trabajador.  Un representante autorizado puede obtener acceso a la información de reclamo.



Formulario
F101-010-999

Otro(s) idioma(s):
Inglés
 
Workplace Posters: Required and Recommended
Fact sheet: Lists posters that Washington State and federal agencies require or recommend employers post in their places of business. The URLs for posters available online and and telephone numbers to request printed posters are also provided. Also includes online resources and contact numbers for state agencies that issue posters.

Cartel
F101-054-000
 
Your Privacy Is Important to Us / Su privacidad es importante para nosotros (English/español)

Fact sheet: Serves as L&I's official privacy notice. States how L&I may use and share the pesonal information it collects. It also informs the public how they can file a complaint if they believe L&I has misused or inappropriately disclosed their personal information.

Hoja de información:  Esta es la notificación oficial de privacidad de L&I.  Establece como L&I podría usar y compartir la información personal que recibe  También le informa al público sobre como puede presentar una queja si cree que L&I ha comprometido o entregado inapropiadamente su información personal.  



Publicación
F101-055-909
 
What Are Your Rights as a Worker? (English/Russian)
Fact sheet: Provides a brief overview of the worker rights administered by the Department of Labor and Industries. These include certain employment-related rights and rights pertaining to workplace safety and workers' compensation benefits.

Publicación
F101-061-404

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

Publicación
F101-061-505

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

Publicación
F101-061-606

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

Publicación
F101-061-707

Otro(s) idioma(s):
Inglés/កម្ពុជា
Inglés/русский
Inglés/Español
Inglés/Việt
 
What Are Your Rights as a Worker? / ¿Cuáles son sus derechos como trabajador? (English/español)

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.

Hoja de información: Proporciona un resumen de los derechos de los trabajadores administrados por el Departamento de Labor e Industrias. Estos incluyen algunos derechos relacionados con el empleo y derechos con la seguridad en el lugar de trabajo y beneficios de compensación para los trabajadores. 



Publicación
F101-061-909

Otro(s) idioma(s):
Inglés/កម្ពុជា
Inglés/한국의
Inglés/русский
Inglés/Việt
 
Guía para el contratista independiente - Una guía detallada para contratar contratistas independientes en el estado de Washington

Folleto: Una guía detallada para contratar contratistas independientes en el estado de Washington.  Esta publicación es una guía general para ayudarlo a entender cómo y cuándo el Departamento de Labor e Industrias aplica las leyes de compensación para los trabajadores a los contratistas independientes.



Publicación
F101-063-999

Otro(s) idioma(s):
Inglés
 
2005 Annual Report - Department of Labor & Industries

Provides a statistical overview of results achieved in fiscal year 2005 (July 1, 2004, through June 30, 2005), budget information and a narrative introduction to the Department of Labor and Industries.



Publicación
F101-068-000
 
If Family Members Work for You, Know Your Obligations (English/Thai)

Fact sheet: Provides an overview and resources to know your obligations when you have family members working for you. Relatives, including children, must be treated as employees with the same rights as any other paid worker in the state of Washington.



Publicación
F101-077-303

Otro(s) idioma(s):
Inglés/中国的
Inglés/한국의
Inglés/русский
Inglés/Español
Inglés/Việt
 
If Family Members Work for You, Know Your Obligations (English/Russian)
Fact sheet: Provides an overview and resources to know your obligations when you have family members working for you. Relatives, including children, must be treated as employees with the same rights as any other paid worker in the state of Washington.

Publicación
F101-077-404

Otro(s) idioma(s):
Inglés/中国的
Inglés/한국의
Inglés/Español
English/Thai
Inglés/Việt
 
If Family Members Work for You, Know Your Obligations (English/Vietnamese)
Fact sheet: Provides an overview and resources to know your obligations when you have family members working for you. Relatives, including children, must be treated as employees with the same rights as any other paid worker in the state of Washington.

Publicación
F101-077-505

Otro(s) idioma(s):
Inglés/中国的
Inglés/한국의
Inglés/русский
Inglés/Español
English/Thai
 
If Family Members Work for You, Know Your Obligations (English/Korean)
Fact sheet: Provides an overview and resources to know your obligations when you have family members working for you. Relatives, including children, must be treated as employees with the same rights as any other paid worker in the state of Washington.

Publicación
F101-077-707

Otro(s) idioma(s):
Inglés/中国的
Inglés/русский
Inglés/Español
English/Thai
Inglés/Việt
 
If Family Members Work for You, Know Your Obligations (English/Chinese)
Fact sheet: Provides an overview and resources to know your obligations when you have family members working for you. Relatives, including children, must be treated as employees with the same rights as any other paid worker in the state of Washington

Publicación
F101-077-808

Otro(s) idioma(s):
Inglés/한국의
Inglés/русский
Inglés/Español
English/Thai
Inglés/Việt
 
If Family Members Work for You, Know Your Obligations / Conozca sus obligaciones cuando miembros de su familia trabajan para usted (English/español)

Fact sheet: Provides an overview and resources to know your obligations when you have family members working for you. Relatives, including children, must be treated as employees with the same rights as any other paid worker in the state of Washington.

Hoja de información:  Proporciona un resumen y recursos para conocer sus obligaciones cuando tiene miembros de la familia trabajando para usted.  Los familiares, incluyendo los niños, deben ser tratados como empleados con los mismos derechos que cualquier otro empleado pagado en el estado de Washington.



Publicación
F101-077-909

Otro(s) idioma(s):
Inglés/中国的
Inglés/한국의
Inglés/русский
English/Thai
Inglés/Việt
 
2006 Annual Report - Department of Labor & Industries
Provides a statistical overview of results achieved in fiscal year 2006 (July 1, 2005, through June 30, 2006), budget information and a narrative introduction to the Department of Labor & Industries.

Publicación
F101-078-000
 
Applying for Your Washington Business License: A Step-by-Step Guide
Pamphlet: Concise, easy-to-read pamphlet that explains the steps to apply for a business license and what to do if you plan to employ workers. Includes how to apply to be a registered construction contractor.

Publicación
F101-079-000

Otro(s) idioma(s):
Español
 
Solicitando su licencia de negocio en Washington: una guía detallada

Volante: Un documento breve y fácil de leer que explica los pasos a seguir para solicitar una licencia de negocio y lo que necesita hacer si planea contratar empleados. Incluye cómo presentar una solicitud para registrarse como contratista de construcción.



Publicación
F101-079-999

Otro(s) idioma(s):
Inglés
 
2007 Annual Report - Department of Labor & Industries

Provides a statistical overview of results achieved in fiscal year 2007 (July 1, 2006, through June 30, 2007), budget information and a narrative introduction to the Department of Labor & Industries.



Publicación
F101-080-000
 
2008 Annual Report for the Washington State Fund: Washington's State-run Workers' Compensation Program

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



Publicación
F101-086-000
 
Small Business Liaison Info Card
Introduces L&I's Small Business Liaison and the services provided, along with information on subscribing to the e-newsletter, L&I News for Small Business.

Publicación
F101-088-000
 
2008 Annual Report - Department of Labor & Industries

Provides a statistical overview of operations in fiscal year 2008 (July 1, 2007, through June 30, 2008), budget information and a summary of accomplishments during the fiscal year.



Publicación
F101-089-000
 
Plan for and Pay Your Taxes
Information card: Introduces Washington State's 28-minute DVD that covers state business taxes and workers' compensation premiums and provides information on how to file.

Publicación
F101-091-000
 
Plan for and Pay Your Taxes DVD

DVD: Covers state business taxes and workers' compensation premiums and provides information on how to file. This 28-minute DVD can help employers plan ahead and obtain more information.



DVD
F101-091-034
 
Challenging Times Demand Our Best
Booklet: Describes how L&I is making changes, both big and small, to better serve our customers and operate efficiently. Three areas of focus are fighting fraud, putting customers first and cutting costs. Features stories about three customers L&I has helped.

Publicación
F101-095-000
 
Strategic Plan
Booklet: Explains the strategic direction of the Department of Labor & Industries. Includes a message from the director, goals, objectives and strategies.

Publicación
F101-099-000
 
Office Locations Map

Fact sheet: Shows which L&I region serves which counties and the location of offices. Side Two lists the address and telephone number for each office.



Publicación
F101-100-000
 
An Employer's Intro to L&I

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



Publicación
F101-101-000
 
Challenges and Change: Managing and Innovating through The Great Recession — L&I from 2005-2012

Booklet: Discusses the impact of the Great Recession on L&I’s programs and highlights accomplishments from 2005 to 2012.



Publicación
F101-102-000
 
L&I Facility Use Application and Agreement for Government Agencies
Use this form if you are a government agency wanting to use the L&I facility located at 7273 Linderson Way SW; Tumwater, WA. (4 pages)

Formulario
F120-097-000
 
Application to Establish an Factory Assembled Structure Deposit Account with the Dept. of Labor and Industries

Use to establish a factory assembled structure (FAS) deposit account. FAS deposit accounts are for businesses or other entities that are not currently licensed or registered with L&I as electrical or construction contractors but are legally required to purchase work permits from L&I. (3 pgs)



Formulario
F120-116-000
 
Protecting Washington Workers / Protegiendo a los trabajadores de Washington (English/español)

DVD: An innovative tool to teach Spanish-speaking workers about workplace rights while introducing English terminology.

DVD: Una herramienta innovadora para enseñarle a los trabajadores que hablan español sobre los derechos laborales mientras se presenta terminología en inglés.



DVD
F130-004-909
 
Employer's Return-to-Work Guide

Pamphlet/booklet: Explains the benefits of 'return to work' from the employer's perspective, describes RTW options, and provides resource and contact information.



Publicación
F200-003-000
 
Your Premium Dollars at Work (2011)

Pamphlet/booklet: Provides information about the programs and services financed with workers' compensation premium dollars, along with statistics such as number of claims, demographics of claims and the most frequent types of injuries.



Publicación
F200-019-000
 
Your Premium Dollars at Work (2012)

Pamphlet/booklet: Provides information about the programs and services financed with workers' compensation premium dollars, along with statistics such as number of claims, demographics of claims and the most frequent types of injuries FY2012 (year ending June 30, 2012). Includes narrative about workers' compensation reforms.



Publicación
F200-020-000
 
Your Premium Dollars at Work (2013)

Pamphlet/booklet: Provides information about the programs and services financed with workers' compensation premium dollars, along with statistics such as number of claims, demographics of claims and the most frequent types of injuries during FY2013 (year ending June 30, 2013). Includes narrative about workers' compensation reforms.



Publicación
F200-022-000
 
Application for Self-Insurance Certification

Used by employers to apply for self-insurance certification.



Formulario
F207-001-000
 
Self-Insurer Accident Report (SIF-2)

Provided to workers by the self-insured businesses or their third party claims administrators to report an industrial injury or occupational disease. This form is not on the internet. If you are an injured worker, ask your employer for a copy of this form. Self-insured businesses or their third party claims administrators may order copies of this form. Cllick the "order It" button below to order paper copies or request the form in MSWord.



Formulario
F207-002-000
 
Self-Insurance Report of Occupational Injury or Disease (SIF-5)

Used by only self-insured employers or their representatives to report initial time loss payments or to request interlocutory, wage, overpayment or closure orders.



Formulario
F207-005-000
 
Quarterly Report for Self-Insured Business

Form used to submit Quarterly Report. If you need a copy of this form to complete your quarterly report, please contact Certification Services at 360-902-6867.



Formulario
F207-006-000
 
Quarterly Statement of Supplemental Benefits Paid for Self-Insured Employers

Used by self-insured employers to report their quarterly statement of supplemental benefits.



Formulario
F207-011-000
 
Quarterly Statement of Supplemental Benefits Instructions

Instructions for filling out the quarterly statement of supplemental benefits.



Formulario
F207-011-111
 
Self-Insured Employers' Medical Only Claim Closure Order and Notice

Used by self-insured employers or their representatives, this is legal notification to an injured worker that their claim is being closed with medical benefits only. This order is used only when neither time loss compensation nor a permanent partial disability award has been paid.



Formulario
F207-020-111

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

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



Formulario
F207-020-999

Otro(s) idioma(s):
Inglés
 
Provider's Initial Report (PIR)

Used by medical providers when reporting initial treatment for an industrial injury or occupational disease for a self-insured claim. The paper version dated 10-2012 is still valid, as is the 01-2014 word fillable version.

Medical providers treating self-insured workers, self-insured businesses, or their third party claims administrators can access this form one of two ways:

  1. Download the Microsoft (MS) Word form and the PDF file with instructions:

           The first file is the PDF instructions.

           The second file is an Office 2003 MSWord document ending in .doc.

           The third file is an Office 2007/2010 version, ending in .docx.

2.  Order paper copies of this form by clicking the “order it” button.



Formulario
F207-028-000
 
Notice to Employees -- Self-Insurance / Aviso a los empleados -- Seguro industrial propio (English/español)

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.

Cartel requerido: para los negocios autoasegurados, describe lo que un trabajador empleado por un negocio autoasegurado debe hacer si le ocurre una lesión o enfermedad relacionada con el trabajo. Aviso: Los empleadores autoasegurados deben colocar este cartel donde los empleados puedan verlo.



Cartel
F207-037-909
 
Special Escrow Agreement
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.

Formulario
F207-039-000
 
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
 
Self-Insurer's Pension Bond

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



Formulario
F207-065-000
 
Self-Insurer's Bond - Existing Liabilities
Used to provide collateral for a self-insured program.

Formulario
F207-068-000
 
Self-Insured Employers' Time Loss Claim Closure Order and Notice

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



Formulario
F207-070-000

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

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



Formulario
F207-070-999

Otro(s) idioma(s):
Inglés
 
Employers' Guide to Self-Insurance in Washington State
Book: Explains the process for employers to provide their own industrial insurance (workers’ compensation) coverage in Washington State. Also reviews surety requirements for self-insurance, reporting and recordkeeping requirements, claims processing, and compliance and legal issues.

Publicación
F207-079-000
 
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
 
Self-Insured Employer Certificate of Excess Insurance

Used to provide excess insurance for a self-insurance program.



Formulario
F207-095-000
 
Preparing for Your Self-Insurance Audit

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



Publicación
F207-110-000
 
Irrevocable Standby Letter of Credit

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



Formulario
F207-112-000
 
Amendment of Irrevocable Standby Letter of Credit

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



Formulario
F207-112-111
 
Memorandum of Understanding Irrevocable Standby Letter of Credit

This memorandum of understanding is between a self-insurer and L&I regading the use of an irrevocable standby letter of credit by the self-insurer as surety for its self-insurance obligations.



Formulario
F207-113-000
 
Transfer of Attending Provider Form for Self Insured Workers

This form is used by self-insured injured workers who want to transfer their medical care.  Self-insured workers should complete the form and send it to their employer or their Third Party Representative.



Formulario
F207-114-000

Otro(s) idioma(s):
Español
 
Formulario para trasferencia de proveedor principal para trabajadores autoasegurados

Formulario: Es utilizado por los trabajadores autoasegurados que desean transferir su cuidado médico. Los trabajadores autoasegurados deben completar este formulario y enviarlo a su empleador o a su Representante de Terceros.



Formulario
F207-114-999

Otro(s) idioma(s):
Inglés
 
Annual Supplemental Surety Information

Used by self-insured employers to assist in fulfilling surety requirements.



Formulario
F207-125-000
 
Special Escrow Account - Amendment Agreement
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.

Formulario
F207-137-000
 
Acknowledgement of Security Interest
Used to acknowledge that funds have been deposited into an account at a bank for the purpose of providing payment for the workers' compensation benefits and assessments in the event of default by the self-insurer.

Formulario
F207-143-000
 
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
 
SIF-5A Cover Sheet: Wage Calculations

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



Formulario
F207-156-000
 
Schedule of Future Payments for the Balance of the Permanent Partial Disability Award

Schedule of Future Payments for the Balance of the Permanent Partial Disability Award.



Formulario
F207-162-000
 
SIF-4 Self Insured Employer's Request for Denial of Claim
Used by self-insured employers or their representatives to notify an injured worker that the employer or representative is requesting that L&I deny their claim.

Formulario
F207-163-000
 
Self-Insured Employers' Permanent Partial Disability Closure Order and Notice - PPD-TL

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



Formulario
F207-164-000

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

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



Formulario
F207-164-999

Otro(s) idioma(s):
Inglés
 
Self-Insured Employers' Permanent Partial Disability Closure Order and Notice - PPD-NTL

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



Formulario
F207-165-000

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

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



Formulario
F207-165-999

Otro(s) idioma(s):
Inglés
 
Self-Insurance Vocational Services Closing Cover Sheet
Used by self-insured employers, their representatives, and vocational counselors to summarize the outcome of a vocational rehabilitation plan when submitting the closing report.

Formulario
F207-171-000
 
Self-Insurance Certification Questionnaire

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



Formulario
F207-176-000
 
Self-Insurance Vocational Reporting Form

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



Formulario
F207-190-000
 
Self Insurance Continuing Education Report of Course Completion

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



Formulario
F207-191-000
 
Self Insurance Continuing Education Sponsor/Instructor Application for Course Approval

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



Formulario
F207-192-000
 
Self-Insurance Electronic Data Reporting System (SIEDRS) Enrollment Form
Used by self-insured employers and third party administrators to enroll for participation in the Self Insurance Electronic Data Reporting System (SIEDRS). F207-197-000 is SIEDRS (Self-Insurance Electronic Data Reporting System) Data Change Request.

Formulario
F207-193-000
 
Self-Insurance Electronic Data Reporting System (SIEDRS): Enrollment Package 2.0

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



Publicación
F207-194-000
 
SIEDRS (Self-Insurance Electronic Data Reporting System) Data Change Request

This is a data change request form. F207-193-000 is the Self-Insurance Electronic Data Reporting System (SIEDRS) Enrollment Form



Formulario
F207-197-000
 
Help for Injured Workers of Self-Insured Businesses
Information card: Introduces the Office of the Ombudsman for Self-Insured Injured Workers. The ombudsman is appointed by the Governor to serve as an independent advocate for the rights of injured workers of self-insured employers.

Publicación
F207-201-000

Otro(s) idioma(s):
Español
 
Ayuda para trabajadores lesionados de empresas autoaseguradas

Tarjeta de información:  Es una introducción a la Oficina del Defensor (Ombudsman en inglés) para trabajadores lesionados autoasegurados.  El defensor es nombrado por el Governador para servir como un defensor independiente de los derechos de los trabajadores lesionados de empleadores autoasegurados.



Publicación
F207-201-999

Otro(s) idioma(s):
Inglés
 
Your Independent Medical Exam: For Employees of Self-Insured Businesses
Pamphlet: Answers the most common questions about when and why an injured worker may be required to attend an independent medical exam. Includes the "IME Travel & Wage Reimbursement Request" form. This publication is for use only by self-insured businesses and their workers.

Publicación
F207-202-000

Otro(s) idioma(s):
Español
 
Su examen médico independiente: para empleadores de negocios autoasegurados

Folleto: Contesta las preguntas más comunes sobre cuándo y por qué puede requerirse que un trabajador lesionado asista a un examen médico independiente.  Incluye el Formulario examen médico Independiente (IME, por su sigla en inglés) Solicitud para el reembolso de gastos de viaje y salario.  Esta publicación es para uso solamente de las empresas autoaseguradas y sus trabajadores.



Publicación
F207-202-999

Otro(s) idioma(s):
Inglés
 
Self-Insurance Continuing Education Application for Course Approval and Attendance

Used by Certified Claims Administrators to apply for continuing education credits for a course attended that has not been approved for credits.



Formulario
F207-206-000
 
Self-Insurance Medical Provider Billing Dispute form

A form for Providers to submit disputes to the department regarding payment of medical provider bills



Formulario
F207-207-000
 
Certificate of Coverage - SAMPLE ONLY

Sample of what the Certificate of Coverage looks like. You must order the form, you cannot download it off the internet.



Formulario
F211-141-000

Otro(s) idioma(s):
Español
 
Certificado de cobertura - ejemplo

Ejemplo que muestra una copia del certificado de cobertura.  Usted debe solicitar el formulario, no puede descargarlo de la Internet.



Formulario
F211-141-999

Otro(s) idioma(s):
Inglés
 
Drywall Industry - Owner/Sub-Contractor Report

Used by drywall companies to file their quarterly report. Must accompany the Supplemental Quarterly Report for the Drywall Industry (F212-051-000).



Formulario
F212-050-000
 
Supplemental Quarterly Report for the Drywall Industry

Used by drywall companies to file their quarterly report. Must accompany the Drywall Industry Owner/Sub-Contractor Report (F212-050-000).



Formulario
F212-051-000
 
Workers' Compensation Employer's Quarterly Report - SAMPLE ONLY

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.



Formulario
F212-055-000
 
Mechanized Logging Supplemental Quarterly Report

Used by an employer to be submitted with the Employer's Quarterly Report for Industrial Insurance as a supplemental reporting form.



Formulario
F212-223-000
 
Quarterly Reporting for Drywall

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



Formulario
F212-224-000

Otro(s) idioma(s):
Español
 
Reporte trimestral para la industria de tabla de yeso

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



Formulario
F212-224-999

Otro(s) idioma(s):
Inglés
 
Notice to Attending Physician of Apprentice / On-the-Job-Training Accident / Incident

A notice to the attending physician that the individual is a Registered Apprentice and to attach this form to the Accident Report of Industry Injury or Occupational Disease (F242-130-000).



Formulario
F100-511-000
 
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
 
Notice of Contest or Objection to Proposed Standards of Apprenticeship

Used by competitor to contest or object to a proposed standards of apprenticeship, new occupation or revised geographical area. Submit this form at least 20 days prior to a Council meeting.



Formulario
F100-516-000
 
Application for out of State Supplemental Reporting

The purpose of form 212-234-000 -Out of state applications- is to provide a means for an employer to formally request to receive the out-of-state supplemental report for a specific year and state. The form will also allow the department to convey out-of-state reporting requirements and to obtain information needed by the department to set a business up for supplemental reporting.



Formulario
F212-234-000
 
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
 
Sports Player Coverage Agreement

Used by a sports team or league and professional athlete (player) to declare that the player's work is principally localized in another state in accordance to the provisions of RCW 51.12.120 and WAC 296-17-32503.



Formulario
F212-242-000
 
Five Steps to File
Flyer: Reviews the steps for filing workers' compensation quarterly reports online and lists the filing due dates.

Publicación
F212-243-000
 
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
 
Taxi-for-hire Vehicle Reporting Requirements
Fact sheet: Provides information for the for-hire industry about mandatory coverage for all for-hire drivers. Includes the different reporting methods and due dates of quarterly reports.

Publicación
F212-245-000
 
Monthly Supplemental Report for Manual Logging

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



Formulario
F212-246-000
 
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
 
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
 
Cancellation of Elective Coverage for Excluded Employments

Used by employers to get the categories of employment that are not considered mandatory to have workers' compensation. If they had elected to have coverage this form is used to cancel previously elected coverage of workers' compensation.



Formulario
F213-005-000
 
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
 
Construction Industry Classification Guide

Book (loose-leaf manual): Helps contractors properly classify for workers' compensation insurance purposes the work being performed by their employees on new wood-frame building construction projects.



Publicación
F213-008-000
 
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
 
Contract: Report By Landowner - Forest, Range & Timber Industry

The landowner needs to complete and submit this form before any contractural agreement with a forest, range and/or timber industry contractor can start any work that is covered by this agreement.



Formulario
F213-010-000
 
Reforestation Contract Supplemental Report - Forest, Range and Timber Industry

Used by an employer to report worker hours for each individual contract with a timber landowner. This is a supplemental document to the Contract: Report by Contractor - Forest, Range & Timber Industry (F213-011-000).



Formulario
F213-013-000
 
Notice of Occupational Disease or Infection

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



Formulario
F242-243-000
 
The ABCs of Classifications in Washington
Book: Aids in understanding Washington State's workers' compensation classification system and how classifications are applied to different types of businesses.

Publicación
F213-022-000
 
Notice of Independent Medical Exam No-Show or Late Cancellation
Notice of Independent Medical Exam No-Show or Late Cancellation

Formulario
F245-382-000
 
Provider Application and Notice for new firms

Complete this application and the StateWide Payee W-9 if you are applying for a firm Provider Number with L&I.



Formulario
F252-088-000
 
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
 
Asbestos Abatement Project Notice of Intent and L&I DOSH Asbestos Program

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



Formulario
F413-025-000
 
Notice of Deficiencies (Crane/Derrick Certification Examination)
Use this form for noting any deficiencies of cranes, derricks, material handling devices, spouts, suckers and similar equipment.

Formulario
F416-054-000
 
Application for Copies of Citation and Notice

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



Formulario
F418-023-000
 
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
 
Electrical / Telecommunication Contractor's License Renewal Notice

This form is used to notify you that your license will expire and for you to use to renew your license.



Formulario
F500-077-000
 
Application for Elective Coverage of Excluded Employments

Used by employers to request coverage of workers' compensation for non-mandatory employment. Shows a list of employment categories to choose from that are not included within the mandatory coverage of workers' compensation.



Formulario
F213-112-000
 
Model Disclosure Statement Notice to Customer

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



Formulario
F625-030-000
 
Construction Lien Notice

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



Formulario
F625-054-000
 
Application for Exclusion/Inclusion - Mandatory Coverage (Family Farm)

To exclude or include coverage for a family farm's children.



Formulario
F213-113-000
 
Contractors: What if You Get a Notice of Infraction?

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



Publicación
F625-097-000
 
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
 
Excluded and Exempt Employments

Quick reference card: Provides a list of employments excluded from workers' compensation coverage, including those eligible for optional coverage. This information is part of the publication, Workers’ Compensation Record Keeping and Report Guides.



Publicación
F214-013-000
 
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
 
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
 
Submission of Provider Credentials for Interpretive Services

Used to apply as a interpretive service provider and to show what language(s) you hold credentials for. F248-011-000 Provider Application and Notice is added to this form.



Formulario
F245-055-000
 
Drywall Contractors

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



Formulario
F214-024-000
 
Financial Statement Sole Proprietors and Individuals

Requesting Financial Information for Sole Proprietors and/or Individuals.



Formulario
F215-039-000
 
Notification to Local Enforcement Agency

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



Formulario
F623-013-000
 
Financial Statement Businesses

Requesting Financial Information for Corporations, LLC and Partnerships.



Formulario
F215-040-000
 
Group vs. Individual Retrospective Rating Participation
Fact sheet: Provides information to employers interested in the Retrospective Rating Program who want to compare group vs. individual participation. Explains the differences in minimum premium amount, fees, services, refund potential, choice, and risk. Also includes contact information for enrolling.

Publicación
F225-016-000
 





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