List of L&I Forms and PDFs

Written By:

l&i lawyer chris sharpe Christopher Sharpe
Home L&I List of L&I Forms and PDFs

The Department of Labor & Industries requires the use of 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 that if you don’t, you will get the information and use the form correctly. 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.

Questions? CONTACT US

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

Activity Prescription Form

Transfer of Care Card

Prescription Reimbursement Form

Travel Reimbursement Request

IME Complaint 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

Work Status Form

Application for LEP Compensation

Activity Prescription Form (APF)

Third-Pary Claims

Third-Party Election Form

Third-Party Recovery Worksheet

Complaint Forms

Workers Comp Discrimination Fact Sheet

Safety & Health Discrimination Complaint Form

Report Safety or Health Hazards

IME Complaint Form 

Meet Our L&I Attorneys

The Walthew Law Firm

The Walthew Law Firm specializes in workers’ compensation. With over 90 years of combined experience, our dedicated attorneys help individuals navigate injury claims and secure the compensation they deserve quickly. We prioritize our clients over businesses and insurers, fiercely advocating for injured workers’ rights and best interests.

Read More About The Walthew Law Firm

How to Get A

Free Consultation & Case Evaluation

Consultation Form

Complete the free case evaluation form below.

Get Started

Phone Call

Available:
Mon-Fri 9am-5pm

Email

Send an email message through our contact form.

Send A Message

Schedule an Online Meeting

Schedule a free 30 minute consultation online.

Free Case Evaluation Form

The information you provide to us is private and confidential information. It will not be disclosed to anyone.

Name(Required)
MM slash DD slash YYYY
Where Did The Injury Occur?(Required)
Tell us about your injuries, your job, and how you were hurt. Tell us about what is on your mind. What can we do for you??
After submitting this form, we will reply to you today or by the next business day.

The Smart Way to Find Out If You Have a Good L&I Case.

Get a free consultation from a lawyer: Tell us about your concerns, and let us show you smart choices you can make for your claim. At the end of the call, you will have fresh ideas and an action plan, no matter what you decide. You will know that you have taken essential steps to get your claim moving in the right direction. Protect yourself and your L&I claim with a free case consultation.

Don't Guess

Don't guess about the value of your claim. Don't compare your claim to someone else's. YOU are unique. Your facts and your injuries make your case unique. Get an expert opinion about your claim from an experienced L&I lawyer. Expertise counts, so use it to your advantage. Consultations are free. This free strategy session will help you understand what is happening and what to do.

Are Attorney Consultations Really Free?

Yes, they are free. Because both you and the attorney want to know if your case is any good. A free phone consultation or email gets that figured out quickly. Questions are answered for free, and no time is wasted. Call or email or fill out our free Case Evaluation form for legal assistance to determine what is going on with your claim and what you should do. A free consultation is going to help.