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Request for Change of Status - Apprenticeship/Training Agreements and Training Agents

Used to request a change of status for apprentices, the training agreements or the training agents. These are normally accompanied by Committee meeting minutes when submitted.



Formulario
F100-021-000
 
Request for Revision of Standards
Used to request a revision of standards except for committee members.

Formulario
F100-030-000
 
Request for Revision of Committee

Used to request revision of committees to include changing the title of the standards, sub-committee members, and committee members.



Formulario
F100-031-000
 
Request for Approval of Proposed Standards
Request for new apprenticeship standards.

Formulario
F100-049-000
 
Request for Cancellation of Program
Used for cancelling an apprenticeship program.

Formulario
F100-303-000
 
Request for Recognition of Apprenticeship Committee

Used to establish a new apprenticeship committee and list it's employer/employee representatives.



Formulario
F100-504-000
 
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
 
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
 
Request for Claim Information

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



Formulario
F101-010-111
 
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
 
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
 
Overpayment Reimbursement Fund Request Coversheet

This form is a coversheet used by Self-Insurance for overpayment reimbursement fund requests.



Formulario
F207-212-000
 
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
 
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
 
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
 
Preauthorization Request for Services for State Fund Workers' Compensation Patients

This form can only be used for services that can be authorized by the claim manager and it should not be used for Utilization Review (Qualis), Provider Hotline or requests to the Occupational Nurse Consultant.  If you are unsure of what services need to be authorized see L&I fee lookup utility at www.Lni.wa.gov/apps/FeeSchedules/

For complete information on all authorization processes please see:  www.Lni.wa.gov/ClaimsIns/Providers/AuthRef/GetAuth.asp



Formulario
F242-397-000
 
Worker Request for Union Dispatch Records

Worker Request for Union Dispatch Records



Formulario
F242-410-000

Otro(s) idioma(s):
Español
 
Travel Reimbursement Request

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



Formulario
F245-145-000

Otro(s) idioma(s):
Español
 
Provider's Request for Adjustment

Providers use this to report total overpayment, partial overpayment and/or underpayment by L&I.



Formulario
F245-183-000
 
Labor and Industries Prosthetic Device Request Form

Labor and Industries Prosthetic Device Request



Formulario
F245-340-000
 
Hearing Aid Repair Authorization Fax Request

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



Formulario
F245-384-000
 
Occupational or Physical Therapy Treatment Authorization Fax Request

Used by a therapy provider/clinic to request authorization for outpatient occupational or physical therapy services for L&I claims.



Formulario
F248-055-000
 
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
 
Medical Device Review Request

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



Formulario
F252-013-000
 
Chronic Opioid Request Form

Use this form to request opioid coverage beyond 12 weeks from the date of injury or surgery, or every 90 days for chronic opioid therapy.



Formulario
F252-091-000
 
Subacute Opioid Request Form

Use this form to request opioid coverage between 6 weeks to 12 weeks from the date of injury or surgery.



Formulario
F252-097-000
 
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
 
OJT Information Request and Recommendation form

VRCs can use this form to request information on a specific on -the -job (OJT) training opportunity listed on L&I's website, or to recommend an OJT training opportunity.



Formulario
F280-032-000
 
Cholinesterase Monitoring Reimbursement Request

Employers use this form to request reimbursement for the reasonable costs of training, travel, recordkeeping, and medical expenses for Cholinesterase Monitoring.



Formulario
F413-062-000
 
Agency Requested Inspection
Used by non-L&I agencies and jurisdictional authorities to request an inspection on an electrical hazard.

Formulario
F500-025-000
 
Request for Duplicate or Replacement License or Certificate

To request a duplicate or replacement of your Washington state electrical license or certificate.



Formulario
F500-032-000
 
Request for Change of Address

Used by electrical licensee to notify L&I of an address change.



Formulario
F500-044-000
 
Electrical Telecommunication Principal Member Owner Update Request

Electrical Telecommunication Principal Member Owner Update Request



Formulario
F500-124-000
 
Board of Boiler Rules Interpretation and Revision Request Form

Used to submit written requests for interpretations and revisions to the definitions, rules and regulations found in WAC 296-104. These must be submitted 45 days prior to the Board of Boiler Rules Meeting date. F620-056-000 Chief Inspector Clarification and Interpretation Request Form must be submitted before using this form.



Formulario
F620-017-000
 
Boiler/Pressure Vessel Clearance Variance Request
To request a clearance variance on a boiler or pressure vessel. You can only mail or fax this form to L&I. E-mailed forms are not accepted.

Formulario
F620-041-000
 
Board of Boiler Rules Extension of Inspection Frequency Request Form
Board of Boiler Rules Extension of Inspection Frequency Request Form

Formulario
F620-055-000
 
Chief Inspector Clarification and Interpretation Request Form

Form is used to ask the Chief Inspector to consider written requests for clarification and interpretation to the definitions, rules and regulations in WAC 296-104. Thsi form must be completed before F620-017-000 Board of Boiler Rules Interpretation and Revision Request form can be submitted.



Formulario
F620-056-000
 
Board of Boiler Rules Washington State Specials Request Form
Board of Boiler Rules Washington State Specials Request Form

Formulario
F620-057-000
 
Extension Request

This form is to request a time extension from an unforeseen circumstances for overdue corrections for conveyances.



Formulario
F621-053-000
 
Owner Requested Red Tag Form

Used by the owner for red tagging a unit that is to be placed or to remain out of service.



Formulario
F621-063-000
 
Request for Duplicate Elevator Certificate

Used to request a duplicate elevator license or a duplicate operating permit for a conveyance.



Formulario
F621-065-000
 
Request for Duplicate Elevator Mechanic License

Request for Duplicate Elevator Mechanic License



Formulario
F621-099-000
 
Permit Refund Request

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



Formulario
F621-105-000
 
Plan Approval Request - Recreational Vehicles and Recreational Park Trailers

Plans to build recreational vehicles or park trailers need approval from L&I. This form is used as part of the approval process.



Formulario
F622-006-000
 
Plan Approval Request - Conversion Vendor / Medical Units

Used in requesting a plan approval for Conversion Vendor or Medical Unit factory-assembled structures.



Formulario
F622-035-000
 
Homeowners Manufactured / Mobile Home Variance Request

This variance request applies only to the installations performed by a previous owner and does not apply to any home during the warranty period.



Formulario
F622-054-000
 
Structural Inspection Request Questionnaire

Structural Inspection Request Questionnaire



Formulario
F622-075-000
 
Roof Affidavit and Structural Inspection Request

The purpose of the manufactured home roof affidavit is to provide timely inspections and communications between the contractor and/or owner and FAS inspectors and field staff.

A structural inspection request questionnaire will not be required when a roof change out occurs if no structural changes are made in the roof sub-surface and roof cavity. Example: Repairing or replacing the roof trusses, rafters, ridge beam and the replacement of not more than (4) 4’x 8’ of roof sheathing.



Formulario
F622-076-000
 
Manufactured Home Installer Certification Tag Transfer Request form

Manufactured Home Installer Certification Tag Transfer Request form



Formulario
F622-079-000
 
Plan Approval Request - Factory Built Structures and Commercial Coaches

A manufacturer of factory-built structures and/or commercial coaches uses this form to submit plans to L&I for review.



Formulario
F623-006-000
 
Subscription Request for Construction Contractor and Electrical Basic - CD

This form is to be used to purchase the CD ROM of registered construction contractors, registered electrical contractors, plumbers and electricians.



Formulario
F625-051-000
 
Request for Archive Records - Contractor Registration

This form is to request L&I to release archive records in the contractors registration section.



Formulario
F625-094-000
 
Contractor Registration Request for Duplicate License or Address Change  

This form may be faxed to the Contractor Registration office in Tumwater.



Formulario
F625-108-000
 
Request for Duplicate or Replacement Certificate

This form is used to request a duplicate or replacement certificate for a plumber or plumber trainee.



Formulario
F627-014-000
 
Plumber Request for Change of Address
Plumber Request for Change of Address

Formulario
F627-039-000
 
Request for Assistance in Obtaining Certified Payroll Records

Used to request copies of Certified Payrolls for prevailing wage projects.



Formulario
F700-141-000
 
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
 
 Safety Standards for WAC 296-56 - Longshore, Stevedore and Waterfront Related Operations

The rules included in this chapter apply to any and all waterfront operations for longshore, stevedore and waterfront  related operations, cargo handling, and related terminal operations and equipment under the jurisdiction of the  Department of  Labor and  Industries.



Manual
F414-034-000
 
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
 
Cranes, Derricks and Material Handling Devices Worksheet for Maritime Industry

Use this form for the inspection of cranes, derricks and materials handling devices on waterfront operations



Formulario
F416-051-000
 
Crime Victims Address Change Request

Crime Victims Address Change Request



Formulario
F800-112-000
 





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