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Activity Prescription Form APF State Fund Claim General info Department of Labor and Industries PO Box 44291 Olympia WA 98504-4291 Fax to claim file 360-902-4567 Self-Insured Claims Contact the Self Insured Employer SIE /Third Party Administrator TPA For a list of SIE/TPAs go to www. Lni. wa.gov/SelfInsured Worker s Name Billing Code 1073M Guidance on back Reminder Send chart notes and reports to L I or SIE/TPA as required. Complete this form onl.

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