Washington Request for Claim Information is a form used by Washington state employers and insurers to obtain records related to a worker's injury claim. This form is typically used when an employee has been injured on the job and the employer or insurer needs to collect necessary information from the employee. It includes sections for the employee's name, date of injury, address, phone number, and other pertinent information. It also includes questions about the employee's medical history, work history, and the details of the injury and treatment received. Depending on the situation, the employer or insurer may also request additional information, such as the opinions or recommendations of medical professionals related to the claim. There are two types of Washington Request for Claim Information forms. The first is the Request for Claim Information form (L&I Form F207-003-000), which is used when an employee has been injured on the job and the employer or insurer needs to collect necessary information from the employee. The second is the Request for Claim Information-Attending Physician statement (L&I Form F207-004-000), which is used to gather information from the employee's attending physician.
Washington Request for Claim Information
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How to fill out Washington Request For Claim Information?
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L&I maintains a list of self-insured employers. Your employer or their representative handles your paperwork and pays for the claim. They will give you a Self?Insurer Accident Report (SIF?2) form. Fill out the form completely and return it to your employer or their representative.
A worker receives a percentage of wages based upon family status and number of dependents at the time of injury. A worker is entitled to 60% of their gross monthly wage. An additional 5% is added for a spouse and 2% for each dependent child, up to five children.
Billing Assistance For bill underpayment disputes only complete and submit the Self-Insurance Medical Provider Billing Dispute form (F207-207-000), or call L&I's Self-Insurance Section at 360-902-6938.
Employees may also file a claim form online at or by phone at 1-877-561-FILE (3453). Workers' compensation claims must be filed within one year of an injury, and within two years of being notified that an illness is work-related.
Contact the Washington State Department of Labor & Industries for information about agency programs and services in your language at 1-800-547-8367. Once you are on the phone, please hold a moment while we call an interpreter to help us.
800-318-6022 If agents are unable to answer your questions immediately, they will schedule a call back for the following day.
By phone Automated Claim Information Line: 1-800-831-5227. Provider Hotline: 1-800-848-0811.