Form F207-155-000 - Workers' Compensation Filing Information - Washington
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1Workers’ Compensation Filing Information
If a Job Injury or Disease Occurs
(Firm Name) ____________________________________
Labor & Industries regulates your employer’s compliance
is subject to Washington industrial insurance laws and
with the law. If you become injured on the job or develop
has been approved by the state to cover its own workers’
an occupational disease, you will be entitled to workers’
compensation benefits. Self-insured employers must
compensation benefits. Your claim will be handled and
provide all benefits required by law. The Department of
your benefits paid by your employer.
In Case of Injury or Disease
Report your injury or disease to your
the L&I medical network. (Find network providers at
supervisor (listed below).
)
Your employer will provide you with a “Self Insured
Complete a “Provider’s Initial Report” form at your
Accident Report” (SIF-2). You must complete this form and
doctor’s office. Have your doctor mail this form to your
file it with your employer if you seek medical treatment.
employer’s claims administration address listed below.
The claims administrator will evaluate your claim for
Get medical care.
benefits. All medical bills that result from an allowable on-
The first time you see a doctor, you may choose any
the-job injury or occupational disease will be paid by your
health-care provider who is qualified to treat your injury.
employer. You may be entitled to wage replacement or
For ongoing care, you must be treated by a doctor in
other benefits. Your employer will explain this to you.
Important!
Your employer cannot deny you the right to file a claim,
Any false claim filed by a worker may be prosecuted to
the full extent of the law.
and your employer cannot penalize you or discriminate
against you for filing a claim. Every worker is entitled to
If you have any questions or concerns, contact your
workers’ compensation benefits for any injury or illness
employer’s representative (at the claims administration
which results from his/her job.
address or phone number below), or call the Department of
Labor & Industries, Self-Insurance Section, 360-902-6901.
Employer Must Complete the Following
Report your injury to:
Claims administration address:
Phone:
F207-155-000 Workers’ compensation filing information [12-2012]
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