Below you will find some basic essential forms needed to manage and administer your worker’s compensation claim.

Activity Prescription Form (pdf)

Your attending physician typically completes this form, in order to certify your inability to work at your job of injury without restrictions.

Worker Status Form (pdf)

Injured workers receiving time-loss benefits are required to complete this form typically every 30 days, in order to contend they are not working, and unable to work, their job of injury.

Affidavit for Time-Loss Benefits (pdf)

If you are contending time-loss for a period of greater than 6 months, or in excess of $10,000, an Affidavit for Time Loss form may be required.

Declaration of Entitlement (pdf)

If you receive a pension, a Declaration of Entitlement is required every year, usually around your pension anniversary date. If you receive a “dependent” or spouses pension, you are required to complete a different Declaration. Please contact our office. 
This form is required to be signed in front of a notary public.

Transfer of Care (pdf)

Used to notify the Department (or Self-insured Employer) of a new attending physician.

Travel Reimbursement Request (pdf)

Used to request reimbursement for travel/mileage expenses for medical appointments, and vocational retraining (including vocational counselor required appointments to our office).
If you are requesting reimbursement for travel for an Independent Medical Examination, please use the IME Travel Reimbursement form below.

IME Travel Reimbursement Request (pdf)

Used to request reimbursement for travel/mileage expenses for Independent Medical Examinations. For medical appointments and vocational reimbursements, please use the form above.

Application to Reopen Claim (pdf)

If the accepted conditions of your claim worsen with objective medical findings, you may be entitled to reopen your claim. This application is required along with relevant medical documentation.

Need an attending physician, or specialist? You can search for approved providers using Labor and Industries’ “Find A Doc” at http://findadoc.lni.wa.gov.

Would you like secure online access to your claim information: You can access your claim through Labor and Industries’ Secure Access at http://secureaccess.wa.gov