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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
 
Maritime Coverage

Used by the employer as a quick reference guide to explain which maritime jobs may or may not be covered by L&I.



Formulario
F212-034-000
 
Coverage Agreement

An agreement between a worker and employer which states the worker's employment is principally localized in Washington state or another state.



Formulario
F212-044-000
 
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
 
Sports Teams Coverage Agreement

Used by a sports team or league covering their Washington players through an out-of-state workers' compensation insurance carrier to confirm compliance with RCW 51.12.120 and WAC 296-17-32503.



Formulario
F212-196-000
 
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
 
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
 
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
 
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
 
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
 
Contract: Report By Contractor - Forest, Range & Timber Industry

This report by the contractor needs to be completed and sent before any contractural agreement with a forest, range and/or timber industry landowner can start any work covered by this agreement.



Formulario
F213-011-000
 
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
 
Reforestation Industry Continuation Sheet (Over $10,000)

Used by contractors to report contracts over $10,000. Reforestation industry contractors must report worker hours for each individual contract with a timber landowner. This form should accompany the quarterly report.



Formulario
F213-015-000
 
Student Volunteers and Workers' Compensation Coverage

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



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

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



Formulario
F213-042-000
 
Application for Exclusion/Inclusion - Mandatory Coverage (Family Farm)

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



Formulario
F213-113-000
 
Record Keeping

Quick reference card: Identifies the type of records employers, including construction contractors, need to keep to allow L&I to compute premiums. This information is part of the publication, Workers’ Compensation Record Keeping and Report Guides.



Publicación
F214-011-000
 
Independent Contractors

Quick reference card: Provides information to help determine whether a "subcontractor" working for you meets the legal requirements to be an independent contractor, or whether he/she is actually a covered worker for workers' compensation (industrial insurance) purposes. This information is part of the publication, Workers’ Compensation Record Keeping and Report Guides.



Publicación
F214-012-000
 
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
 
Computing Worker Hours

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



Publicación
F214-014-000
 
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
 
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
 
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
 
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
 
Formulario de verificación de empleo

El trabajador lesionado debe completarlo si no puede trabajar debido a una lesión en el lugar de trabajo y su empleador no le está pagando su salario completo.  



Formulario
F242-052-999

Otro(s) idioma(s):
Inglés
 
Verification of School Enrollment

Used by the student and a school official each quarter to verify school enrollment.



Formulario
F242-055-000

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
 
Reclamo para beneficios de pensión presentado por el cónyuge, pareja doméstica registrada o los hijos

Usado por el cónyuge o dependientes de un trabajador fallecido. EL accidente fatal o enfermedad ocupacional del trabajador que ocurrió en el transcurso del empleo.  Esta solicitud es necesaria para determinar si el(los) solicitante(s) tienen derecho a recibir beneficio de sobreviviente.



Formulario
F242-056-999

Otro(s) idioma(s):
Inglés
 
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
 
Reclamo para beneficios de pensión presentado por los dependientes

Usado por los dependientes de un trabajador fallecido para presentar un reclamo para beneficios.



Formulario
F242-062-999

Otro(s) idioma(s):
Inglés
 
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
 
Continuación del Historial de Trabajo y de Enfermedad Ocupacional

El trabajador lesionado llena este formulario para documentar una posible enfermedad ocupacional y para mostrar su historia de trabajo.



Formulario
F242-071-911

Otro(s) idioma(s):
Inglés
 
Historial de trabajo (enfermedad ocupacional)

El trabajador lesionado llena este documento para presentar su historia de trabajo.  El formulario de continuación a esta página es F242-071-911.



Formulario
F242-071-999

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

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



Publicación
F242-104-000

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

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



Publicación
F242-104-999

Otro(s) idioma(s):
Inglés
 
Address Change Request for Pensioners

Used by the pensioner to notify L&I of a new mailing address. L&I must receive this form by the first day of the month so your monthly payment is received in a timely manner.



Formulario
F242-107-000

Otro(s) idioma(s):
Español
 
Solicitud para cambio de dirección para pensionados

Utilizado por el pensionado para notificarle a L&I de una nueva dirección postal.  L&I debe recibir este formulario para el primer día del mes para que el pago mensual pueda recibirse a tiempo.



Formulario
F242-107-999

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

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



Formulario
F242-173-911

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

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



Formulario
F242-173-922

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

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



Formulario
F242-173-933

Otro(s) idioma(s):
Inglés
 
Declaración de derechos para los beneficios de un trabajador totalmente discapacitado bajo las Leyes del Seguro Industrial

Usado por un trabajador permanentemente y totalmente discapacitado.  Este formulario debe completarse, firmarse, notarizarse y devolverse a L&I dentro de 30 días para que los beneficios no sean interrumpidos.



Formulario
F242-173-944

Otro(s) idioma(s):
Inglés
 
Authorization for Deposit of Payments

Used by pensioner to authorize L&I to deposit the pension payment to any designated financial institution.



Formulario
F242-174-000

Otro(s) idioma(s):
Inglés/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
 
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
 
Statement for Retraining and Job Modification Services

Bill form for providers that bill the department for claim-related retraining and job modification services. See the General Provider Billing Manual (248-100-000) for information on completing this form.



Formulario
F245-030-000

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
 
Tarjeta para transferencia de caso

Usada por los trabajadores lesionados para notificar al gerente de reclamo y solicitar autorización para transferir el cuidado a un doctor diferente.



Formulario
F245-037-999

Otro(s) idioma(s):
Inglés
 
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
 
Su examen médico independiente

Folleto: Respuestas a las preguntas más comunes sobre los exámenes médicos independientes y cuándo y por qué podría requerirse que un trabajador lesionado asistiera a uno.  Incluye el formulario examen médico independiente (IME, por su sigla en inglés) - Solicitud para el reembolso de gastos de viaje y salario. Este formulario es solamente para el uso de negocios autoasegurados y sus trabajadores.



Formulario
F245-224-999

Otro(s) idioma(s):
Inglés
 
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
 
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
 
Hotline Tips for Medical Services Providers
Fact sheet: Provides tips to help medical service providers quickly obtain answers to claims and billing questions. Introduces L&I's Provider Hotline, Interactive Voice Response Message System and online Claim & Account Center.

Publicación
F248-040-000
 
Payroll Service Provider - Quarterly Reporting Bulk Filing Enrollment Form

Used by payroll services to enroll and register with L&I for downloading/uploading account information from the Express Filing site using an electronic list (text file) of accounts.



Formulario
F248-343-000
 
Third Party Recovery Worksheet

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



Formulario
F249-006-111
 
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
 
Individual Retrospective Rating Plan Agreement
Used by employers to set up an agreement between them and L&I authorizing their participation in retrospective rating.

Formulario
F250-003-000
 
Application for Group Retrospective Rating

Used by organizations to set up an agreement with L&I authorizing their participation in retrospective rating.



Formulario
F250-004-000
 
Application for Group Membership & Authorization for Release of Insurance Data
Used by employers who want to join a retrospective rating group; also, to authorize Labor & Industries to release the employers' insurance data to the retrospective rating group they want to join.

Formulario
F250-016-000
 
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
 
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
 
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
 
Cuestionario sobre la pérdida del sentido auditivo en el trabajo

Usada por el trabajador lesionado que ha presentado un reclamo por pérdida de audición para proporcionar información más específica referente a cómo ocurrió la pérdida de audición.  Esto es solicitado por el gerente de reclamo y enviado al trabajador lesionado.



Formulario
F262-016-999

Otro(s) idioma(s):
Inglés
 
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
 
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
 
Competent Person Evaluation - Fall Restraint & Fall Arrest

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



Formulario
F417-102-000
 
Competent Person Evaluation - Excavation & Trenching

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



Formulario
F417-104-000
 
Alleged Safety Or Health Hazards (DOSH Complaint Form)

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



Formulario
F418-052-000

Otro(s) idioma(s):
Español
 
Presuntos riesgos de Salud y Seguridad (Formulario de queja de la División de Seguridad y Salud Ocupacional)

Los empleados usan este formulario de queja para reportar las condiciones de trabajo que ponen en peligro la seguridad y salud de los trabajadores.



Formulario
F418-052-999

Otro(s) idioma(s):
Inglés
 
Non-Compliance Report - Boiler & Pressure Vessel Inspection
Used by L&I inspectors when a boiler or pressure vessel does not pass inspection. You can only mail or fax this form to L&I. E-mailed forms are NOT accepted.

Formulario
F620-012-000
 
Application for Certificate of Competency as an Inspector of Pressure Retaining Items

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



Formulario
F620-040-000
 
Farm Labor Contractor Complaint Form

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



Formulario
F700-109-000

Otro(s) idioma(s):
Español
 
Formulario de queja en contra de un contratista de trabajores agrícolas

Usado para presentar una queja contra un contratista agrícola,  hacendado, empleador u otro en lo que se refiere a una infracción.



Formulario
F700-109-999

Otro(s) idioma(s):
Inglés
 
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
 
Court Form Granting Permission for Employment of Minors

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



Formulario
F700-119-000
 
Application to Reopen Crime Victim Claim Due to Worsening of Condition

Benefits are limited to $50,000 per claim. if your claim has met or exceeded this cap, your reopening application will be denied and we will be unable to pay any further benefits. Used by victims of crime and medical or mental health providers to request a claim be reopened.



Formulario
F800-031-000

Otro(s) idioma(s):
Español
 
Application for Benefits - Crime Victims

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



Formulario
F800-042-000

Otro(s) idioma(s):
Español
Español
 
Request for Survivor Counseling Benefits / Solicitud para beneficios de apoyo para los sobrevivientes (English/español)  

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

Utilizado por miembros de la familia inmediatos de víctimas de homicidio para solicitar asesoría de salud mental.



Formulario
F800-057-909
 
Crime Victims Provider's Request for Adjustment

Used by providers to request an adjustment to their bill if their entire bill was paid in error, or if a portion of the bill was overpaid or underpaid. Attach required reports and/or documentation to support the request.



Formulario
F800-064-000
 
Statewide Payee Registration and W-9 Form Crime Victims

Used by a provider assisting victims of crime to obtain a taxpayer ID number. Note: Register now for direct deposit available January 2013.



Formulario
F800-065-000
 
Know What to Expect: How Recoveries and Settlements May Impact Your Crime Victim Claim

Pamphlet and form: Explains third-party liability, recoveries and settlements. A crime victim or the Crime Victims Compensation Program may pursue monetary restitution from someone who caused or contributed to a crime victim's injury. Explains the purpose of the form and why individuals who file a crime victims claim are required to complete it.



Publicación
F800-074-000
 
Statement for Crime Victim Miscellaneous Services

Used by the provider or supplier for reimbursement of the following services - dental, glasses, home health, nursing home serivces, medical equipment, prosthetics-orthotics, transportation, vocational, retraining and other.



Formulario
F800-076-000
 
Provider Change Form for Crime Victims Compensation

Providers use to inform L&I that they have changes to their account. Such as changes to their Tax ID address/name, business address, billing address, name, or termination of account. This also includes a W-9 form.



Formulario
F800-089-000
 
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
 
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
 
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
 
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
 
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
 
Comentarios Sobre el Exámen Médico Independente

Usado por el trabajador lesionado para proporcionarle comentarios a L&I sobre su examen médico reciente de un Examen Médico Independiente (IME, por su sigla en inglés).



Formulario
F245-053-999

Otro(s) idioma(s):
Inglés
 
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
 
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
 
Formulario de historial de empleo

Usado por el trabajador lesionado para reportar su historial de empleo y el salario de cada trabajo durante los últimos tres años



Formulario
F242-109-999

Otro(s) idioma(s):
Inglés
 
Travel Reimbursement Request - Crime Victims

If you are considered a victim of crime, use this form to track your travel expenses for medical, retraining or vocational services or for an independent medical exam. You should have approval from your claim manager before you travel.



Formulario
F800-049-000
 
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
 
Summary of Agricultural Employment Regulations and Farm Contractor Requirements

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



Publicación
F700-124-000
 
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
 
Preparing for Your Self-Insurance Audit

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



Publicación
F207-110-000
 
The ABCs of Classifications in Washington
Book: Aids in understanding Washington State's workers' compensation classification system and how classifications are applied to different types of businesses.

Publicación
F213-022-000
 
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
 
Attending Provider's Return-to-Work Desk Reference
Book: Discusses best practices in occupational medicine that help return an injured worker to his/her job as soon as medically possible. Identifies resources available from L&I and explains how to bill for return-to-work services. Three hours of Category 1 CME credit are offered for completing an online self-assessment. Go to www.CMECredits.Lni.wa.gov.

Publicación
F200-002-000
 
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
 
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
 
Self-Insurance Certification Questionnaire

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



Formulario
F207-176-000
 
Getting Back to Work: It's Your Job and Your Future
Pamphlet/booklet: Briefly explains steps to return to work quickly and minimize the economic impact of time-loss. Also provides helpful resources. Intended for injured workers.

Publicación
F200-001-000

Otro(s) idioma(s):
Español
 
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
 
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
 
On-the-Job Training
Postcard: For employers; summarizes the benefits of providing on-the-job training to an injured worker. The other side is for injured workers who want to return to work; explains how on-the-job training can help them. Includes website address and contact information.

Publicación
F200-021-000
 
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
 
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
 
Performance Based Physical Capacities Evaluation

Used by occupational and physical therapy providers as an optional reporting format for a Performance-based Physical Capacities Evaluation.



Formulario
F245-023-000
 
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
 
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
 
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
 
Interested Party Checklist for the Filing of Prevailing Wage Complaints

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



Formulario
F700-129-000
 
Termination of Agreement (Rescission)
To be filled out by the injured worker who wants to return hearing aids.

Formulario
F245-050-000
 
Declaración para servicios misceláneos

Formulario:  Es utilizado por proveedores y trabajadores lesionados para cobrarle al Departamento por servicios tales como, cuidado dental; lentes; cuidado de enfermería en el hogar; equipo médico, servicios de intérprete; servicios que los trabajadores pagan por su cuenta y otros servicios.



Formulario
F245-072-999

Otro(s) idioma(s):
Inglés
 
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
 
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
 
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
 
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
 
Letter of Intent for School Enrollment
Use by a full-time student who is entitled to receive pension benefits. The student must be at least 18 years old and no older than 23 years old. This form is to prove the students intention to register in an accredited school during the next quarter/semester.

Formulario
F242-382-000

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
 
Crime Victim Compensation Program Sexual Assault Exam Report

A form used by physicians, hospitals and clinics to provide information and reporting to the Crime Victims Compensation Program.



Formulario
F800-098-000
 
Vocational Technical Stakeholder Group (VTSG) Application
This form is for recruiting private sector vocational counselors to be on the Vocational Technical Stakeholder Group (VTSG). The form is made available on the department’s vocational website when recruiting for new members to assist the department in addressing vocational issues and formulating policy. Prospective applicants are expected to download, sign, and return the form to PSRS for consideration.

Formulario
F280-049-000
 
Massage Therapy Treatment Authorization Fax Request

Used by a licensed massage practitioner/clinic to request authorization for outpatient massage therapy services for L&I claims.



Formulario
F248-357-000
 
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
 
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
 
Billing Guidelines for Sexual Assault Examinations: Crime Victims Compensation Program

Provides information health-care providers need to bill the Crime Victims Compensation Program for medical services.



Manual
F800-100-000
 
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
 
Regresando a trabajar es su trabajo y su futuro

Folleto:  Explica brevemente los pasos para que el trabajor pueda regresar a trabajar rápidamente y reducir el impacto económico del tiempo perdido.  También proporciona recursos útiles.  Destinado para trabajadores lesionados.

 

 



Publicación
F200-001-999

Otro(s) idioma(s):
Inglés
 
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 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
 
Housing and Board Cost Encumbrance
To record the costs for housing and board. For use only with plans approved after 1/1/2008.

Formulario
F245-372-000
 
Training Plan Cost Encumbrance

To record the training costs. For use only with plans approved after 1/1/2008.



Formulario
F245-374-000
 
Transportation Cost Encumbrance

To record the costs for transportation. For use only with plans approved after 1/1/2008.



Formulario
F245-375-000
 
Plan Time Encumbrance
To record the work plan time. For use only with plans approved after 1/1/2008.

Formulario
F245-376-000
 
Programa con Incentivos para Volver a Emplear a Trabajadores Lesionados

Folleto:  Describe el Programa con Incentivos para Volver a Emplear Trabajadores Lesionados y los beneficios que reciben los empleadores cuando contratan trabajadores con el programa.  En general, estos son trabajadores cuyas lesiones o enfermedad ocupacional les impide regresar a su antiguo trabajo. 



Publicación
F280-021-999

Otro(s) idioma(s):
Inglés
 
Plan Development Quality Assurance Review Form

For use internally by L&I Vocational Service Specialists (VSSs) to determine if all required components are included in the submitted plan. Can be used by VRCs as a tool. DO NOT SUBMIT TO L&I.



Formulario
F280-007-000
 
Assessment Eligible Quality Assurance Review Form

For use internally by L&I Vocational Service Specialists (VSSs) to determine if all required components are included in the submitted assessment.  Can be used by VRCs as a tool.  DO NOT SUBMIT TO L&I.



Formulario
F280-008-000
 
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
 
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
 
Insurer Activity Prescription Form

Used by health-care providers to communicate an injured worker's status, physical capacities, inability to work (time-loss) and treatment plans. To print an APF, click on the title of the form in the box above.



Formulario
F242-385-000

Otro(s) idioma(s):
Inglés/Español
 
Solicitud para cambio de dirección para trabajadores lesionados

Para ser completada y firmada por un trabajador lesionado del Fondo estatal para notificarle a L&I de un cambio de dirección.  Todos lo cambios de dirección deben someterse por escrito y estar firmados por el trabajador lesionado.



Formulario
F242-388-999

Otro(s) idioma(s):
Inglés
 
Job Analysis

Used by vocational rehabilitation counselors (VRCs) to document the physical demands of jobs.



Formulario
F252-072-000
 
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
 
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
 
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
 
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
 
Job Analysis Summary

Summary that goes on top of a job analysis.  Gives the physician a snapshot of the physical demands of a job.



Formulario
F252-101-000
 





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