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Labor & Industry Forms

The Department of Labor & Industries requires the use of and supplies many forms. The most commonly requested and popular forms are listed below. See the DLI website for additional forms.

Be careful and smart about completing these forms. They are provided for your use with the assumption that you either know what to put in them or if you don’t you will get the information. If completion of these forms is difficult and/or questions get raised in the filling out process then consider getting advice on the handling of these forms or your claim.

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Claim Filing

Report of Industrial Injury or Occupational Disease (Accident Report)

Application to Reopen Claim due to Worsening Condition

Claim information

Request for Claim Information

Medical

Transfer of Care Card

Prescription Reimbursement Form

Travel Reimbursement Request

Occupational Disease

Occupational Disease & Employment History Form

 

Pension

Claim for Pension by Dependents

Claim for Pension by Spouse or Children

Declaration of Entitlement for Dependent of Deceased Worker Benefits under Industrial Insurance

Declaration of Entitlement for Guardian Benefits under Industrial Insurance

Declaration of Entitlement for Totally Disabled Worker Benefits under Industrial Insurance

Declaration of Entitlement for Widow or Widower Benefits under Industrial Insurance

Pension Benefits Questionnaire

Verification of School Enrollment

Time Loss

Affidavit for Time Loss Compensation Benefits

Work Status Form

Application for LEP Compensation

Time Loss Notification Form

Complaint Forms

Workers Comp Discrimination Fact Sheet

Safety & Health Discrimination Complaint Form

Report Safety or Health Hazards

Third Party Claims

Third Party Election Form

Third Party Recovery Worksheet

What’s Next?

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