L&I Accident Report Form Pdf. Filing this form does not constitute an admission of liability. (also known as report of accident, or roa) (f242‑130‑000).
Accident Report Form Template Business
Please note that the custodian of records will handle this request in conjunction with all other request for records. Department of labor (see instructions on reverse) office of workers' compensation programs omb no. Web if you will be working at a location without internet access, download and save or print the accident/incident report form (pdf) prior to leaving internet service. Web report of accident (roa) form: Employees shall use this form to report all work related injuries, illnesses, or “near miss” events (which could have caused an injury. Web activity prescription form (apf) billing code: How to file an l&i claim if you suffer an injury at work or develop an occupational disease, you need to file a claim right away. Web online via our filefast tool by signing into my l&i. Web washington state department of labor & industries 1073m (guidance on back) reminder:
Employees shall use this form to report all work related injuries, illnesses, or “near miss” events (which could have caused an injury. Department of labor (see instructions on reverse) office of workers' compensation programs omb no. Send chart notes and reports to l&i or sie/tpa as required. 401 sw topeka blvd, suite 2. However, the report / case / incident number is required on each. Web employer's first report of injury. Employer's telephone number ( ) 31. Report of industrial injury or occupational disease form. Due to the volume of requests for. Web if you will be working at a location without internet access, download and save or print the accident/incident report form (pdf) prior to leaving internet service. A three car accident, add another report form as needed.
