Request For Claim Information {F242-430-000}

Request for Claim Information For State Fund Claims Mail To: Department of Labor & Industries PO Box 44291 Olympia WA 98504-4291 For Self-Insured Claims Mail To: Self-Insurance PO Box 44892 Olympia WA 98504-4892 For the worker or worker's representative OR The employer or employer's representative This form must be completed in full. Copies of documents are a chargeable item. Claim Number Worker's Name Name of Person Making Request Address City I am Worker State Zip Code Other I am requesting my claim file. I am requesting the following information from my claim file (for example: "The panel exam of February 2, 2013" etc.): I am the worker's authorized representative requesting the claim file for the worker named above. I understand that the file contains confidential information and by accepting the file, I accept full responsibility for any use made of this information. My authorization is: On File Attached I am the employer or employer's representative requesting the claim file for the worker named above. I understand that the file contains confidential information and by accepting the file, I accept full responsibility for any use made of this information. Signature Date For Department Use Only Action taken on request: Name of Person Taking Action: Date Action Taken: Section/Office: F242-430-000 Request for Claim Information 06-2017 American LegalNet, Inc. www.FormsWorkFlow.com