Apply for a Claim Resolution Settlement

Add a claim number for the same worker

All steps are required.

* = required field

1. Please tell us who the injured worker is

Injured worker name: *

2. Please tell us about yourself

Your name: *
Your email:
Country: *	Enter your country: *
Address: *
City *
State: *	Zip Code: * -
State/Province/Region:
Postal Code: *
Primary phone: *
Secondary phone:
Primary phone: *	- - Ext:
Secondary phone:	- - Ext:

3. Why is a Claim Resolution Settlement right for this claim?

Why do you prefer a Claim Resolution Settlement? *

How would a Claim Resolution Settlement benefit your long-term plans? *

4. How did you hear about the Claim Resolution Settlement option?

Check all that apply

Letter from L&I
L&I website
Medical provider
Vocational counselor
Claim manager
Employer
Attorney
Other

* I certify that all of the information provided as part of this application is true and correct to the best of my knowledge.

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Injured worker name:
Your name:
Claim numbers:
Your email:
Address:	,
Primary phone:	Type:
Secondary phone:	Type:
Why do you prefer a Claim Resolution Settlement?
How would a Claim Resolution Settlement benefit your long–term plans?
Files:
How did you hear about the Claim Resolution Settlement option?

Need help with the website? Call Web Customer Support between 8 a.m.-5 p.m. (Pacific) at 360-902-5999.
More information about the program? Call the Claim Resolution Settlement unit between 8 a.m.-5 p.m. (Pacific) at 360-902-6101.