When Washington L&I or a self-insurer asks an independent medical examiner for physical capacities, the examiner records them on this one-page estimate. Based on the clinical evaluation and other test results, it shows how long the worker can sit, stand and walk in an 8-hour day, lifting and carrying limits by weight and frequency, repetitive hand and foot use, postural activities and environmental restrictions.
The L&I-approved independent medical examiner completes and signs the form, marking N/A for any item they cannot answer. When several examiners perform one exam, only one of them bills for the estimate.
Download the current version from the source each time; forms change without notice.
Independent Medical Exam Doctor's Estimate of Physical Capacities
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
When the insurer requests it as part of an independent medical exam. L&I's fee schedule says the estimate, local code 1105M, must be requested by the insurer, so examiners complete it when the assignment asks for physical capacities and return it with the IME report.
Mark it N/A. The form's instructions say to complete each item based on your clinical evaluation and other testing results, and to mark N/A for any item you do not believe you can answer. Percentages refer to an 8-hour workday.