Click on the form to download and print.
- Department of Labor and Industries / Self-Insured Employer Forms
- Activity Prescription Form
- Affidavit for Time Loss Compensation
- Application for Loss of Earning Power
- Application to Reopen Claim Due to Worsening Condition
- Authorization to Release Claim Information
- Case Transfer Card
- Consultation Referral
- Declaration of Entitlement for Totally Disabled Workers
- Interpretive Services Appointment Record
- Opioid Progress Report Supplement for Chronic, Non-Cancer Pain
- Pension Benefits Questionnaire
- Provider Application
- Travel Reimbursement Form
- Prescription Reimbursement Form
- Worker Verification Form
- Your Independent Medical Examination (with Travel Reimbursement Form)