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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
 
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
 
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
 
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

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

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



Formulario
F800-042-000
 
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
 
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
 
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
 
Self-Insurance Certification Questionnaire

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



Formulario
F207-176-000
 
Construction Contractor's Application for Workers' Compensation Account with No Workers or Hours

Used by employers with no employees or worker hours to report but need an open account for contract bidding process.



Formulario
F625-077-000
 
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
 
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
 
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
 
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
 
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
 
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
 
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
 
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
 
Plan Room and Board Cost Encumbrance

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



Formulario
F245-372-000
 
Training Plan Cost Encumbrance

To record the work plan time. 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
 
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
 
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
 
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 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 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
 
Application for Pension Benefits by Spouse or Children

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



Formulario
F242-391-000

Otro(s) idioma(s):
Español
 
Solicitud para beneficios de pensión presentado por el cónyuge o los hijos

Formulario:  Usado por el cónyuge o dependiente elegido por el trabajador fallecido para recibir un beneficio de sobreviviente.  En el momento en que se determinó que el trabajador estaba permanentemenre y totalmente discapacitado el/ella tomó la decisión de dejar el beneficio de sobreviente al cónyuge o dependiente si el trabajador fallecía.



Formulario
F242-391-999

Otro(s) idioma(s):
Inglés
 
Helping Providers Understand the Crime Victims Compensation Program
Fact sheet: Answers questions doctors and mental health counselors may have about the Crime Victims Compensation Program and billing for services. Also suggests steps these providers can take to speed up reimbursement.

Publicación
F800-102-000
 
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
 
Pension Benefits Questionnaire

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



Formulario
F242-393-000

Otro(s) idioma(s):
Español
 
Solicitud para reabrir un reclamo debido al empeoramiento de la condición

Los beneficios están limitados a $50,000 por reclamo. Si su reclamo ha llegado o excedido  este límite, su solicitud de reapertura será negada y no podremos pagar beneficios futuros.  Usado por las víctimas de crimen y proveedores médicos o de salud mental para solicitar la reapertura de un reclamo.



Formulario
F800-031-999

Otro(s) idioma(s):
Inglés
 
Cuestionario para beneficios de pensión

Usado por un trabajador lesionado que recibe una orden estableciendo que él o ella está total y permanentemente discapacitado.  Este cuestionario debe completarse en su totalidad y debe adjuntarse todos los documentos necesarios antes de que pueda calcularse sus opciones de beneficios de pensión.



Formulario
F242-393-999

Otro(s) idioma(s):
Inglés
 
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
 
Temporary Services Guide to Workers' Compensation Insurance

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



Manual
F213-019-000
 
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
 
Affidavit for Time Loss Compensation Benefits

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



Formulario
F242-395-000

Otro(s) idioma(s):
Español
 
Solicitud para reabrir un reclamo debido al empeoramiento de la condición 

Usada por los trabajadores lesionados y doctores para solicitar la reapertura de un reclamo de lesión industrial o enfermedad ocupacional que ha estado cerrado por más de 60 días.



Formulario
F242-079-999

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

Publicación
F262-032-000
 
Victim Verification Form

For use by crime victims requesting wage replacement compensation



Formulario
F800-110-000

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

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



Formulario
F242-395-999

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

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



Formulario
F252-072-000
 
Workers' Compensation Record Keeping and Reporting Guides

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



Publicación
F212-222-000
 
Formulario de verificación de empleo

Para ser utilizado por las víctimas de crimen que están solicitando compensación de reemplazo de salario.



Formulario
F800-110-999

Otro(s) idioma(s):
Inglés
 
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
 
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
 
CVCP Opioid Progress Report Chronic, Non-Cancer Pain and Treatment Agreement.

Crime Victims Compensation Opioid Progress Report Chronic, Non-Cancer Pain and Treatment Agreement.



Formulario
F800-116-000
 
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
 
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.

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
 
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
 
Application for Loss of Earning Power (LEP) - Compensation Medical

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



Formulario
F242-208-000

Otro(s) idioma(s):
Inglés/Español
Español
 
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
 
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
 
Stay at Work: A new program to help employers keep injured workers on the job--pays half the wage plus expenses

Pamphlet/booklet: Provides an overview Stay at Work, a financial incentive program that encourages Washington employers to find light-duty or transitional jobs for workers recovering from on-the-job injuries. Includes information on eligibility, how to apply, and where to get more information.



Publicación
F243-006-000

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

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

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



Formulario
F242-079-909

Otro(s) idioma(s):
Inglés
Español
 
3 Things to Know about L&I's Medical Provider Network

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



Publicación
F242-406-000

Otro(s) idioma(s):
Español
 
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
 
Tres cosas que debe conocer sobre la Red de proveedores médicos de L&I

Volante: Le explica a los trabajadores la información básica sobre la Red de proveedores médicos de L&I. Los trabajadores cubiertos por L&I y por las empresas autoaseguradas pueden utilizar el volante.  Se aplica a los trabajadores en el estado de Washington.  Incluye información para comunicarse por la Internet y el número de teléfono.  



Publicación
F242-406-999

Otro(s) idioma(s):
Inglés
 
Crime Victims Compensation Subacute Opioid Request Form

Use this form for Crime Victims Compensation to request opioid coverage between 6 weeks and 12 weeks from date of injury or surgery.



Formulario
F800-119-000
 
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
 
Occupational Disease Work History - Continuation

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



Formulario
F242-071-111

Otro(s) idioma(s):
Español
 
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
 
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
 
Business and Industry Category Guide

Manual: Provides assistance to retro groups in determining if a prospective employer qualifies for their retrospective rating group program.



Manual
F250-025-000
 
Crime Victims' Statement for Compound Prescription

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



Formulario
F800-067-000
 
Worker Request for Union Dispatch Records

Worker Request for Union Dispatch Records



Formulario
F242-410-000

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

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



Publicación
F700-173-000
 
Competent Person Evaluation - Excavation & Trenching

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



Checklist
F417-104-000
 





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