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