Injured by a third party? You have legal options Protect your rights: Complete the enclosed form promptly. In Washington, if you believe your workplace injury was caused by someone other than your employer or co-worker, you may take legal action against this "third party." Your important rights are explained in this brochure. Be sure to read it carefully before you complete the enclosed form. American LegalNet, Inc. www.FormsWorkFlow.com PUBLICATION F249-008-000 [08-2014] Know your rights Read XX this important information before you fill out the enclosed form. You XX have certain rights if a third party may have caused your workplace injury. We sent you this form because your Report of Accident indicated that your workplace injury or illness may have been caused by a third party. A third party is someone other than your employer or a co-worker. Some examples of third parties: Under Washington's workers' compensation law, you ordinarily cannot take legal action against an employer or co-worker responsible for your workplace injury or occupational disease. However, you can take legal action against other people that caused your injury. If you wish to take action, you may pursue it yourself with your own attorney, or you may ask the Department of Labor & Industries (L&I) to consider pursuing it. Your legal options You XX lose these important rights if you do not return this form to us. If you do not complete and return the enclosed form, the right to take legal action may be automatically assigned to the Department of Labor & Industries. In that case, you would no longer have the right to recover personal injury damages yourself or with your attorney, but you will receive a portion of any recovery made by L&I. The driver of the car that hit you. A manufacturer of the defective product that injured you. A property owner who failed to properly maintain the building where you were working when you were hurt. The owner of an animal that bit you. A worksite general contractor if you were employed by a subcontractor. Your XX benefits continue during any Important Note: We believe that all of the information in this pamphlet is correct. However, it is not intended to be an interpretation of the law. Please consult an attorney or call L&I for more detailed information that relates to your specific situation. legal action taken. If you are now receiving workers' compensation benefits and decide to pursue a third-party legal action, we would not stop or change your benefits until, or unless, you receive a financial recovery. American LegalNet, Inc. www.FormsWorkFlow.com Carefully read the following information and make your decision. Option A: You XX DO want to take legal action against the third party yourself, with your own attorney. Questions? Call: 360-902-5100 Write: Third Party Section Department of Labor & Industries P.O. Box 44288 Olympia, WA 98504-4288 Visit: www.3rdParty.Lni.wa.gov Walk-in: Visit your local L&I office Directions: Locate the office nearest you at www.Offices.Lni.wa.gov or check your local telephone directory. If you receive a financial settlement or recovery... Through your own legal action: XX You must report to us the amount of any settlement offered to you before you take action. This is because you are required to repay any claim benefits you received from us after you were injured. When a settlement is made, funds are distributed according to a formula set by Washington State law. The formula divides recovered funds among you and your attorney (if you have one) and L&I, to reimburse us for the amount of claim benefits. Depending on the amount you receive, payment of your benefits may stop after you receive a settlement, but could resume, depending on how long your claim remains open. Check Option A on the enclosed form and mail it to us. You and your attorney, if you have hired one, must notify us when you file your lawsuit and keep us informed of its progress. If you do not diligently pursue your legal action, we can petition the court to have it assigned to us. Option B: You XX DO NOT want to take legal action yourself, but will give this right to L&I. Choose Option B on the enclosed form and mail it to us. You are "assigning" to the Department of Labor & Industries the right to take legal action against the third party. Under this option, L&I may decide not to take any action at all. However, if we did take legal action, you would not pay upfront legal fees. Fees are deducted from recoveries, but if no recovery is made, no fees are required. Through L&I action: XX If we recover settlement funds from a person or organization found to be responsible for your injury, funds will be distributed according to the formula set by Washington State law. You will receive a portion of any recovery made. American LegalNet, Inc. www.FormsWorkFlow.com You XX do not believe a third party caused your injury. Check the box next to "No Third-Party Responsibility." Explain why in the "Description and Location of Accident" box at the bottom of the form, sign and return it to us. Third Party Election Form Injured Worker Name Email Address Claim Number Injured by a third party? You have legal options. Protect your rights. My address has changed. Check the box and write your NEW address below. Injured Worker's Mailing Address City State Zip Make your choice. Then sign and date in the appropriate place. My attorney or I will seek to recover my personal injury damages. Option A I understand that I must notify the Department of Labor & Industries if or when I file a lawsuit. If I choose to hire an attorney, I give L&I permission to communicate with him/her. I also understand that if I receive money as a result of a legal settlement or award, I must repay my workers' compensation benefits to L&I. Before I settle my case, or allocate economic and non-economic damages in a settlement, I must obtain L&I's written approval if the settlement will result in the Department receiving less than the amount of benefits paid, or estimated to be paid. If I have an attorney, I have provided his/her name, address and telephone numbers below. Signature Date Attorney's Address City State Zip X Attorney's Name Attorney's Phone ( Option ) I authorize L&I to consider recovery of my personal injury damages. I give up my right to take legal action against the third party to recover damages, both economic and non-economic, on my own or with an attorney. I give this right to L&I and I understand that L&I