Your Name *
Your Company *
Injured Worker's Name *
L&I Claim Number
Date of Injury *
This information will be used by L&I to determine benefits payments (if applicable).
Select the type of pay this employee receives: HourlyHourly - On Call StatusFlat RateCommissionPieceworkSalaryOther
If Flat Rate, Commission, or Piecework - please indicate the average monthly wage for 6 months prior to the date of injury.
If On Call - please indicate the average monthly wage for 6 months prior to the date of injury.
If other - please indicate type
Rate of Pay . per HourDayWeekMonthYear
Hours Worked per Day *
Days worked per Week *
Does this worker earn bonuses or spiffs? * YesNo
What is the average monthly amount paid in bonuses or spiffs over the last 12 months?
Does the worker earn overtime? * YesNo
Average Hours of Overtime worked per month *
Will you keep this employee on salary? (paying regular wages while off work) YesNo
If you have paid regular salary what dates have been paid?
Were you contributing to this employee's (or family) health care benefits on the date of injury? * YesNo
Amount paid for health care benefits including vision and dental? Health care is paid per...N/AHourDayMonthPercentage of Salary
If percentage, average paid per month:
Did the employee miss time from work? YesNo
Last Date Worked *
Do you know the Return to Work date? YesNo
Return to Work Date *
If the Return to Work date is unknown, please list the anticipated return to work date. *
Is the worker currently working with restrictions or in a light duty job? YesNoWorking regular duty
Is temporary light duty available for this worker? YesNo
If no light duty is available contact ICM to learn about a return to work solution using Light Duty Pathway or visit lightdutypathway.com.
Do you question the validity of this claim? NoYesPossibly
If you question the validity, please list any supporting information.
Employer Additional Comments
If you would like an electronic version of this form, complete your e-mail below.
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