Washington injured workers apply for loss of earning power (LEP) benefits, a partial wage replacement, with this one-page packet. The worker reports hours and gross earnings, the employer certifies wages paid, and the attending physician confirms the work-related diagnosis and whether the disability limits the worker to modified duty or reduced hours. The worker then mails the finished packet to L&I's Claims Section.
The attending physician completes the physician's section: diagnosis, modified duty or reduced hours, restrictions, return to the pre-injury schedule, factors impeding recovery, MMI and permanent impairment. The worker completes and signs the worker's section, and the employer completes its section or attaches payroll records.
Download the current version from the source each time; forms change without notice.
Application for L.E.P. Compensation MED
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The attending physician. L&I's payment policy says only the attending provider on the claim may sign and be paid for the LEP form, and only when the insurer requested it. The worker and employer complete their own sections before the worker mails the packet to L&I.
The diagnosis due to the workplace injury or illness; whether the disability allows only modified or lighter duty or reduced hours, with hours and days per week; the physical restrictions; return to pre-injury work; impeding factors; whether the condition has reached maximum medical improvement; and whether permanent impairment will result.