Forms
Find common and frequently used forms here.
Worker Status Form
A Worker Status Form in a Washington State L&I claim is a short form that updates L&I on whether an injured worker is currently working, unable to work, or has returned to work in any capacity. It also reports changes in wages, hours, or employment, helping L&I determine eligibility for time-loss or other benefits. Completing it accurately ensures the claim stays up to date and benefits are paid correctly.
Activity Prescription Form
The Activity Prescription Form (APF) is a medical form used in Washington State L&I claims where the treating provider outlines the worker’s injury-related restrictions and what activities they can safely perform. It helps employers and L&I understand whether the worker can return to full duty, light duty, or cannot work at all. The APF guides return-to-work planning and determines eligibility for benefits like time-loss compensation.
Travel Reimbursement Request
The Travel Reimbursement Request form is used by injured workers in a Washington State L&I claim to request reimbursement for travel-related costs (like mileage, parking, or lodging) incurred for medical or vocational appointments. It requires prior authorization from the claim manager and must include trip details (date, destination, reason) and receipts for most expenses.
Travel Reimbursement Request - IME
A travel reimbursement request form for an IME is used in a Washington State L&I claim when a worker needs to be repaid for travel costs related specifically to an Independent Medical Examination. The worker lists mileage, parking, tolls, or other approved expenses for the IME appointment and submits receipts when required. L&I uses this form to reimburse necessary travel costs so long as the IME was scheduled or authorized by the department.
Employment Security Dept. Records Request
The Washington State Employment Security Department (ESD) Self-Request for Records Form is used by individuals to request copies of their own records kept by ESD. These records may include unemployment claim information, wage and employment history, or other documents ESD maintains about the requester. The form verifies the requester’s identity, specifies which records are being requested, and ensures ESD can securely release personal information only to the person it belongs to.