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Form

Description

WA_FROI.pdf Report of Accident (ROA) Workplace Injury, Accident or Occupational Disease
101-002-000.pdf Employers' Guide to Workers' Compensation Insurance in Washington State
101-002-999.pdf Employers' Guide to Workers' Compensation Insurance in Washington State (Spanish Version)
reopen.pdf Application to Reopen Claim
reopen_sp.pdf Application to Reopen Claim (Spanish)
address.pdf Address Change Request for Pensioners
242-107-999.pdf Address Change Request for Pensioners (Spanish)
120-211-000.pdf Payment Method Authorization
120-211-999.pdf Payment Method Authorization(Spanish)
252-029-000.pdf Assessment Closing Report
252-081-000.pdf Making the Best Treatment Choice for Your Chronic Low-Back Pain
252-081-999.pdf Making the Best Treatment Choice for Your Chronic Low-Back Pain (Spanish)
252-095-000.pdf Opioid Treatment Agreement
252-095-999.pdf Opioid Treatment Agreement (Spanish)
242-208-000.pdf Application for L.E.P. Compensation Med
242-208-909.pdf Application For L.E.P. Compensation Med (Spanish)
242-209-909.pdf Application for L.E.P. Voc (Spanish)
lepvoc.pdf Application for L.E.P. Voc
time-loss.pdf Affidavit for Time-Loss Compensation
280-057-000.pdf Retraining Plan Option Form
280-057-999.pdf Retraining Plan Option Form (Spanish)
release.pdf Authorization to Release Claim Information
release_sp.pdf Authorization to Release Claim Information (Spanish)
deposit.pdf Authorization for Deposit of Payments
transfer.pdf Case Transfer Card
assumption.pdf Employers Job Description
history.pdf Employment History Form
hearingloss1.pdf Occupational Disease Employment History Hearing Loss
hearingloss1sp.pdf Occupational Disease Employment History Hearing Loss (Spanish)
hearingloss-q.pdf Occupational Hearing Loss Questionnaire
hearingloss-q-sp.pdf Occupational Hearing Loss Questionnaire(Spanish)
req-medforms.pdf Medical Forms Request
disease1.pdf Occupational Disease and Employment History
disease2.pdf Occupational Disease and Employment History (Continuation)
242-071-999.pdf Occupational Disease and Employment History (Spanish)
242-071-911.pdf Occupational Disease and Employment History (Continuation) (Spanish)
req-info.pdf Request for Claim Information
worker.pdf Work Status Form
worker_sp.pdf Work Status Form (Spanish)
dependents.pdf Claim for Pension by Dependents
spouse-children.pdf Claim for Pension by Spouse or Children
spouse-children_sp.pdf Claim for Pension by Spouse or Children (Spanish Version)
242-422-000.pdf Declaration of Entitlement For Dependent of Deceased Worker Benefits Under Industrial Insurance
242-422-999.pdf Declaration of Entitlement For Dependent of Deceased Worker Benefits Under Industrial Insurance (Spanish)
242-421-000.pdf Declaration of Entitlement For Disabled Child or Guardian Benefits Under Industrial Insurance
242-421-999.pdf Declaration of Entitlement For Disabled Child or Guardian Benefits Under Industrial Insurance (Spanish)
242-423-000.pdf Declaration of Entitlement For Totally Disabled Worker Benefits Under Industrial Insurance
242-423-999.pdf Declaration of Entitlement For Totally Disabled Worker Benefits Under Industrial Insurance (Spanish)
242-420-000.pdf Declaration of Entitlement For Surviving Spouse or Registered Domestic Partners Benefits Under Industrial Insurance
242-420-999.pdf Declaration of Entitlement For Surviving Spouse or Registered Domestic Partners Benefits Under Industrial Insurance (Spanish)
school.pdf Letter Of Intent For School Enrollment
calculation.pdf Third Party Recovery Worksheet with Calculations
245-145-000.pdf Travel Reimbursement Request
agreement6.pdf Accountability Agreement
agreement6_sp.pdf Accountability Agreement(Spanish)
280-029-000.pdf On the Job training Accountability Agreement
280-029-999.pdf On the Job training Accountability Agreement(Spanish)
280-056-000.pdf Option 1 Plan Modification Accountability Agreement
OT_PTrequest.pdf Occupational or Physical Therapy Treatment Authorization Fax Request
pre-job.pdf Pre-Job Accommodation Assistance Application
pce.pdf Performance Based Physical Capacities Evaluation
dr_estimate.pdf Doctor's Estimate of Physical Capacities
dr_worksheet.pdf Doctor's Worksheet for Rating Dorso-Lumbar and Lumbo-Sacral Impairment
hearing_worksheet.pdf Hearing Impairment Calculation Worksheet
notice_occ.pdf Notice of Occupational Disease or Infection
245-055-000.pdf Submission of Provider Credentials for Interpretive Services
OT_PTprogress.pdf Physical Therapy / Occupational Therapy Progress Report to Claim Managers
245-100-000.pdf Statement for Pharmacy Services
jobmodassist.pdf Job Modification Assistance Application
252-110-000.pdf Buprenorphine Transdermal Patch Authorization Request Form
opioid.pdf Opioid Progress Report
252-072-000.pdf Job Analysis
Poster.pdf POSTER - Notice to Employees
416-081-909.pdf POSTER - Job Safety and Health Law
700-074-909.pdf POSTER - Your Rights as a Worker in Washington State
appelective.pdf Application for Elective Coverage of Excluded Employments
cancelelective.pdf Cancellation of Elective Coverage
cancelexcluded.pdf Cancellation of Elective Coverage for Excluded Employment
212-234-000.pdf Application for out of State Supplemental Reporting
212-233-000.pdf Washington Workers Insured Out-of-State: Employer's Supplemental Quarterly Report for Workers' Compensation
inclusion.pdf Application for Inclusion on List of Eligible Attorneys
selfinsurer.pdf Agreement of Assumption (Certified Self-Insurer)
application.pdf Application for Self-Insurance Certification
MOCC.pdf Self-Insured Employers' Medical Only Claim Closure Order and Notice
207-020-999.pdf Self-Insured Employers' Medical Only Claim Closure Order and Notice (Spanish)
TLCC.pdf Self-Insured Employers' Time Loss Claim Closure Order and Notice
PPD-NTL.pdf Permanent Partial Disability Closure Order and Notice
PPD-TL.pdf Permanent Partial Disability Closure Order and Notice
207176000.pdf Self-Insurance Certification Questionnaire
SI_Poster.pdf POSTER - Self-Insurance Poster (English and Spanish)
249-008-000.pdf Third Party Election Form / Brochure- Injured by a Third Party?
assignment.pdf Assignment of Account Agreement
filing_info.pdf NOTICE - Workers Compensation Filing Information
101-165-000.pdf BROCHURE - Pocket Guide to Workers Rights
101-165-909.pdf Pocket Guide to Worker Rights(English/Spanish)
207-201-000.pdf BROCHURE - Help for Injured Workers of Self-Insured Businesses
207-201-999.pdf BROCHURE - Help for Injured Workers of Self-Insured Businesses (Spanish)
280-021-000.pdf BROCHURE - Preferred Worker Program
280-021-999.pdf BROCHURE - Preferred Worker Program (Spanish)
memo.pdf Memorandum of Understanding
207-085-000.pdf A Guide to Workers' Compensation Benefits. For Employees of Self-Insured Businesses.
207-085-999.pdf A Guide to Workers' Compensation Benefits. For Employees of Self-Insured Businesses. (Spanish)
160-006-000.pdf Brochure- Need A Doctor ?
160-006-999.pdf Brochure - Need A Doctor ? (Spanish)
independent.pdf Independent Contractor Guide
independent_sp.pdf Independent Contractor Guide (Spanish)
212-250-000.pdf Independent Contractor or Covered Worker? - Your rights to workers' compensation, minimum wage and overtime
212-250-999.pdf Independent Contractor or Covered Worker? - Your rights to workers' compensation, minimum wage and overtime (Spanish Version)
SSoffset.pdf SSO Calculations Only
education.pdf Continuing Education Report of Course Completion
240-003-000.pdf BROCHURE - Settling your L&I claim might be right for you. An option for injured workers 50 or older
240-003-999.pdf BROCHURE - Settling your L&I claim might be right for you. An option for injured workers 50 or older (Spanish)
207-006-000.pdf Quarterly Report for Self-Insured Business
207-011-000.pdf Quarterly Statement of Supplemental Benefits Paid
SIF-4.pdf Self-Insured Employers Request for Denial of Claim
SIF-5.pdf SI Report on Occupational Injury or Disease
SIF-5A.pdf SIF Cover Sheet- Wage Calculations
letter_of_credit.pdf Irrevocable Standby Letter of Credit
amend_letter_of_credit.pdf Amendment of Irrevocable Standby Letter of Credit
memo_letter_of_credit.pdf Memorandum of Understanding Irrevocable Letter of Credit
245-365-000.pdf Provider Account Change Form
242-385-000.pdf Activity Prescription Form
consultation.pdf Consultation Referral
functional.pdf Functional Progress Form
thirdparty.pdf Self-Insured Third Party Election Form
addresschg.pdf Address Change Request for Injured Workers
242-388-999.pdf Address Change Request for Injured Workers (Spanish)
242-412-909.pdf Injured workers: Leaving Washington,but still need treatment?
280-061-000.pdf Brochure: Workers: Activity coaching can help you get back to doing what you love
280-061-999.pdf Brochure: Workers: Activity coaching can help you get back to doing what you love (Spanish Version)
212-248-000.pdf Brochure: Massage Therapist: Independent Contractor or Covered Worker?
700-182-000.pdf Application to Employ Workers with a Disability at a Subminimum Wage
240-002-000.pdf Application for Structured Settlement
240-002-999.pdf Application for Structured Settlement (Spanish)
245-183-000.pdf Provider's Request for Adjustment
242-393-000.pdf Pension Benefits Questionnaire
242-429-000.pdf L&I Workers' Compensation: We're Here for You
242-429-999.pdf L&I Workers' Compensation: We're Here for You (Spanish Version)
245-439-000.pdf Nurse Case Management (NCM) Progress Report
245-441-000.pdf Nurse Case Management (NCM) Qualis Progress Report
245-442-000.pdf Nurse Case Management (NCM) Initial Care Management Plan
280-062-000.pdf Providers: Refer your patients to Activity Coaching to help them recover