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 421 State Forms found

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Authorization to Release Claim Information (Chinese Simplified)

 F101-010-220 07-2023

Authorization to Release Claim Information (Somali)

 F101-010-303 07-2023

Data Change Request SIEDRS (Self-Insurance Electronic Data Reporting System)

 F207-197-000 10-2023

Designation of Beneficiary Claim Resolution

 F240-006-000 12-2020

Designation of Beneficiary Claim Resolution (Spanish)

 F240-006-999 12-2020

Claim Resolution Settlement Income and Expense Worksheet (Cambodian)

 F240-007-220 3-2023

Affidavit for Time Loss Compensation Benefits (Arabic)

 F242-395-203 01-2009

Affidavit for Time Loss Compensation Benefits (Korean)

 F242-395-255 01-2009

Affidavit for Time Loss Compensation Benefits (Tigrinya)

 F242-395-312 01-2009

Affidavit for Time Loss Compensation Benefits (Vietnamese)

 F242-395-319 01-2009

Declaration of Entitlement For Disabled Child or Guardian Benefits Under Industrial Insurance (Spanish)

 F242-421-999 11-2019

Declaration of Entitlement for Dependent of Deceased Worker Benefits Under Industrial Insurance

 F242-422-000 04-2017

Authorization to Release Information

 F262-005-000 07-2015

DOSH Retaliation Complaint

 F416-011-000 09-2023
Disclaimer: These forms may not be the most recent version. Washington may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on this site. Please check official sources.
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