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
Review Your Claim Online – See for Yourself What is Happening on Your Claim
Medical
Prescription Reimbursement Form
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
Application for LEP Compensation
Activity Prescription Form (APF)
Third Pary Claims
Third Party Recovery Worksheet
Complaint Forms
Workers Comp Discrimination Fact Sheet
Safety & Health Discrimination Complaint Form
Report Safety or Health Hazards
