L&I Injury Claim Forms and Publications

Filing an L&I Injury Claim

Injured workers should be aware that L&I does not necessarily represent the worker. After suffering an occupational injury or illness, Washington State workers are often overwhelmed by the challenge of navigating a highly bureaucratic Workers’ Compensation system that involves hundreds of regulations and forms, and thousands of administrators beholden to the complicated rules governing the L&I claims process. Becoming lost in the details of L&I statutes, or filling out forms without knowledge of Workers’ Compensation law, can have an adverse effect on your financial compensation.

Submitting an L&I form without attorney counsel could be detrimental to the outcome of a workers’ injury claim; workers are strongly advised to consult a Seattle Workers’ Compensation lawyer prior to completing and submitting any L&I form.

L&I Claims Contact Information

L&I FORMS AND PUBLICATIONS

(All forms available in English and Spanish)

Application to Reopen Claim Due to Worsening Condition (form F242-079-000)

This form is completed by injured workers and doctors for application to reopen a Workers’ Compensation injury or occupational disease claim that has been closed for a period exceeding 60 days.

Authorization to Release Claim Information (form F101-010-000)

A worker submits this form to designate a person as his or her authorized representative for the worker’s claim. Authorized representatives have access to that worker’s L&I claim information.

Case Transfer Card (form F245-037-000)

Injured workers submit the case transfer card to L&I claim managers to request authorization to transfer their medical care to a different doctor.

Claim for Pension By Dependents (form F242-062-000)

Dependent survivors of a deceased worker (including household members or other individuals with a relation of financial dependency) will file form F242-062-000 to claim death benefits under L&I.

Claim for Pension by Spouse or Children (form F242-056-999)

Used by surviving spouse or children of a deceased worker to file a claim for benefits.

Declaration of Entitlement for Dependent of Deceased Worker Benefits Under Industrial Insurance (form F242-173-333)

Dependents of a worker whose death was caused by or related to a workplace injury or accident must complete, sign, notarize and return this form to L&I within 30 days for continued benefits.

Declaration of Entitlement for Guardian Benefits under Industrial Insurance (form F242-173-222)

The Declaration of Entitlement for Guardian Benefits will be completed by the official guardian or other person who has custody of the minor children/dependents of a deceased worker to claim pension benefits for those children/dependents.

Declaration of Entitlement for Totally Disabled Worker Benefits Under Industrial Insurance (form F242-173-444)

Totally and permanently disabled workers must complete, sign, notarize and return this declaration of entitlement to L&I in 30 days or less for non-interruption of benefits.

Declaration of Entitlement for Widow or Widower Benefits Under Industrial Insurance (form F242-173-111)

If you are the widow or widower of a spouse who has died from a work-related injury, illness or accident, this form must be completed, signed, notarized and returned to L&I within 30 days for non-interruption of your benefits.

Affidavit for Time Loss Compensation Benefits (form F242-395-999)

This form to be completed and submitted by an injured worker claiming eligibility for payment of time-loss benefits for a period that either exceeds six months or a value of $25,000. However, injured workers seeking compensation for current missed work-time resulting from a work-related injury should use the F242-052-999 Worker Verification Form.

Occupational Disease & Employment History (form F242-071-000)

Injured workers who believe they have developed an occupational disease will use this form to document their condition and provide relevant details of their work history.

Occupational Disease Employment History Hearing Loss (form F262-013-000)

Injured workers who have already filed an occupational hearing loss claim will use this form to provide relevant details of their employment history and document their noise exposure within each position.

Overview of occupational hearing loss at the National Institute for Occupational Safety and Health.

Learn more about occupational hearing loss.

Pension Benefits Questionnaire (form F242-393-000)

This pension benefits form is used by injured workers who receive an order stating that he or she is totally permanently disabled. The questionnaire must be completed and submitted with all necessary accompanying documents before the individual’s pension benefits can be calculated.

Report of Industrial Injury or Occupational Disease (Accident Report ) (ROA) (form F242-130-000)

This form is completed by injured workers, physicians and employers to report an occupational injury or illness. The ROA is not currently available on the internet. Injured workers will request copies of the form from their doctor. This link can be used to order the ROA form from the Department of Labor and Industries. Order F242-130-999 from the warehouse to receive the instructions in Spanish.

Request for Claim Information (form F101-010-111)

This form is submitted by workers, workers’ representatives or employers to request L&I claim information.

Statement for Pharmacy Services (F245-100-000)

L&I requires this form to reimburse injured workers for the cost of prescriptions less any co-payment. The form must be filled out by the attending pharmacist. While the attached statement may not be accepted by all Medical Bill Processors due to the absence of a barcode, it will be accepted by L&I.

Workers’ Compensation Discrimination Fact Sheet (available in English and Spanish)

L&I’s fact sheet on Workers’ Compensation Discrimination (form F262-249-909)

explains a workers’ legal right to file a workplace injury claim and details the process for filing a complaint in the case of discrimination or retaliatory action.

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