The downloadable forms below are forms from the office of Wayerski Zmolek.
Please download and fill out the appropriate form and bring it with you to your initial appointment with your attorney.
Travel Reimbursement Form:
Injured workers use this form to request reimbursement for travel expenses used to receive treatment, retraining and/or vocational services. These forms will be accepted by L&I. They may not be accepted by all Medical Bill Processors due to lack of a barcode.Activity Prescription Form:
This form is used by health-care providers to communicate an injured worker's status, physical capacities, verification of inability to work (time-loss) and treatment plans.Worker Verification Form:
Description: Completed by the injured worker if they are unable to work due to a workplace injury AND their employer is not paying their full wages.Pension Declaration of Entitlement:
Description: Used by a totally permanently disabled worker. This form must be completed, signed, notarized and returned to L&I within 30 days for non interruption of benefits.