Department of Labor and Industries PO Box 44291 Olympia WA 98504-4291 Authorization to Release Claim Information To be completed by the worker You or your delegate can also view your claim file documents online at the department's Claim and Account Center. For more information go to: www.ClaimInfo.Lni.wa.gov. Worker Information: Worker name Address City State Zip Code Claim number Phone number: I designate the following individual as my authorized representative and they have the following access. Representative name Address City State Zip Code Phone number: I am authorizing the release of my claim file for review. I am authorizing the mailing of my claim file, payments, and correspondence from this date forward to the authorized representative's address listed above. I am authorizing the release of information regarding sexually transmitted infection (STI), if any, as defined by state law. I am authorizing, but limit the release of information to the authorized representative from my claim following: (for example ­ all non-medical records, the panel exam of February 4, 2013, etc. please list the limitation below). This authorization will remain in effect until revoked in writing. Worker signature Date F101-010-000 Authorization to Release Claim Information 12-2013 American LegalNet, Inc. www.FormsWorkFlow.com