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.

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 

 

How to get a Free Consultation and Case Evaluation.

There are 4 different ways you can get a free initial consultation. Take your choice:

  1. Complete the Free Case Evaluation Form below
  2. Call / text: (206) 343-1988
  3. Email us: [email protected]
  4. Schedule an appointment via Calendly

We usually reply to forms, texts, and emails within 1 business day.

Free Case Evaluation Form

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Name
Ex. Back injury preventing me from working
Ex. How injury occurred, were you at work? Have a personal injury caused by someone else? Who was involved, did you require medical treatment, how can we help you?
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The Smart Way to Find Out If You Have a Good Case.

Get a free consultation from a lawyer: Tell us about your concerns and let us show you some smart choices you can make for your claim. At the end of the call, no matter what you decide to do, you will have fresh ideas and an action plan. You will know that you have taken important steps to get your claim moving in the right direction. Protect yourself and your L&I or Personal Injury 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. Get an expert opinion about your claim, from an experienced lawyer. Expertise counts, so use it to your advantage. Consultations are free. This strategy session will help you get informed.

Are Attorney Consultations Really Free?

Yes, they are. 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 and no time is wasted. Call 206-343-1988 or email and let us help you figure it out with a free consultation.

Chris Sharpe

Meet Chris Sharpe

Christopher Sharpe is the go to attorney for injured persons. His law firm is helpful, honest, and knowledgeable about workers' compensation and personal injury law in the State of Washington. Chris has been helping injured Washington State workers for over 40 years. He has built a successful law practice by thoroughly educating, honestly helping, and successfully representing workers throughout Washington State.

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