Get Claim Manager Authorizations - L&i - Access Washington 2017-2025

Filling out the Claim Manager Authorizations - L&I form online can be a straightforward process if you follow the correct steps. This guide will provide you with clear, step-by-step instructions tailored to your needs.

Follow the steps to complete the Claim Manager Authorizations form online.

1. Press the ‘Get Form’ button to access the form and open it in the online editor.
2. Provide the employer's certified name in the 'Employer' field.
3. Enter the self-insured employer's UBI number in the designated field.
4. Input the self-insured employer's account ID with L&I accurately.
5. Fill in the self-insurance claim number under 'Claim No.'.
6. If applicable, include the name of the service organization managing the claims in the 'Service Co.' field.
7. Check all applicable boxes under the 'Type of SIF-5' section, indicating the purpose of your submission.
8. For final SIF-5 submissions, indicate if health care contributions ceased during time loss benefits.
9. Fill in the injured worker's name in the 'Claimant' section.
10. Provide the current mailing address for the injured worker.
11. Record the date of the injury in its corresponding field.
12. Input the last day the injured worker was employed as a result of the injury.
13. Enter the date of the first payment made to the injured worker.
14. Provide the claim arrival date when benefits were applied for.
15. Include the date the injured worker returned to work, leaving it blank if they have not returned.
16. Fill in the date the physician released the worker to return to work, with supporting medical documentation.
17. Indicate the date the injured worker first received treatment for their condition.
18. Provide a detailed account of the compensation paid, specifying periods and amounts.
19. Indicate whether payments included time loss and specify totals.
20. Complete questions regarding the claim's medical status and injuries, answering yes or no as appropriate.
21. Fill in the attending physician's name and mailing address.
22. Use the remarks section for any additional information or required explanations.
23. Complete the section for claim closure if applicable; otherwise, disregard it.
24. Finally, enter the date, name, and phone number of the person authorizing the form before submitting.

Complete and submit your Claim Manager Authorizations - L&I form online for a smooth processing experience.