Forms

IMPORTANT: If you do not receive a letter from us confirming that we have received the accident report card, please call our office! If we have no record of the accident being reported within 90 days, we can not process bills for payment. 

This card is supplied in order to facilitate quick reporting of all injuries sustained during performance of duty. It is recommended that a supply be on hand in each station and that one be completed and sent in immediately following any injury, no matter how minor it appears. In the event that the post office should lose the card, the stub should be filled out and retained by the department as proof of mailing. All accidents must be reported to the State Board in writing within 90 days of occurrence or no claims can be paid by the State Board.

This form will need to be submitted annually for retirees who rejoin the department while collecting a retirement pension. Please find the amount of the next year's disability fee in the annual letter sent toward the end of the year regarding annual fees.

All departments are welcome to use this form to send to billing departments of local doctors, clinics, and/or hospitals to properly introduce the process of submitting claims. This will let them know not to send claims to L&I, which department they should send the claims to, and that claims will be audited according to L&I fee schedules. 

This checklist will be required when submitting documentary evidence to prove volunteer firefighter or reserve office service.

View checklist directions.

This form must be completed by a representative at the pensioner's bank.  Please be sure to indicate whether the account is checking or savings. A check will be sent the first month after the information was entered along with a letter asking the pensioner to verify that the account information is correct. If it is not, contact the Board for Volunteer Firefighters as soon as possible, otherwise, all future payments will deposit automatically.

Consistent with Federal law, Title 38, Part III, Chapter 43, Subchapter II, Section 4318, the BVFF & RO will allow service credit to be granted and pension payments to be made up in instances of interruptive military service for members who must interrupt their volunteer fire or reserve officer duties to provide protection for the nation in times of crisis when they are called to active duty military status. The Board adopts the following procedures regarding interruptive Military Service Credit:

Procedure:

All eligible members, as defined below, must complete the Board's Interruptive Military Service Request Form and submit it within five (5) years of said military service. Additionally, fire departments shall notify the Board, in writing, when a member exits service due to a military call up, and when a member returns to employment. This notification shall take place within 30 days of the respective events. 

Eligibility:

1. Must have service in the Army, Navy, Air Force, Marine Corps, Coast Guard, National Guard, or their reserve units. 
2. Must apply for reemployment with the employer who employed the member prior to the member's call-up within 90 days of the member's honorable discharge, unless the time deployed was:
   • 30 days or less: the employee must report to the employer no later than the beginning of the first regularly scheduled work day/drill/meeting (whichever is first) following the completion of military service
   • more than 30 days, but less than 181: the employee must submit for reemployment within 14 days, or within a reasonable time if the employee is not at fault
   • more than 181 days: the employee must submit for reemployment within 90 days if the employee is hospitalized as a result of his/her military service, (s)he has a maximum of two years to recover before submitting for reemployment
3. Must be part of a Title 10 Call-up as noted on a DD214 and NGB22, copies of which must be provided to the BVFF & RO.
4. The employer (fire or law enforcement department) must notify the BVFF & RO within 30 days of the member's reemployment.
5. The member must apply to receive the credit, using the appropriate form, and pay the prescribed fees within five (5) years of returning to employment.

Payment:

• The State Board shall establish the member's service credit and bill the employer for its contribution required under RCW 41.24 for the period of military service, plus interest based upon the documentation received with the member's application form.
• The member must pay his/her portion of the fees, unless the employer has elected to make the member's payments for the other members of the department. 
• The member may not make payments in excess of a five (5) year cumulative period of service.

This form is used to request all payments from the Volunteer Firefighters’ and Reserve Officers’ Relief and Pension Fund. The name of the person or firm to receive payment must appear in the box at the top left. The member should be named and the description section should list the amount granted and the reason for the claim (disability compensation, physician’s services, hospital services, reimbursement for..., refund fees, etc.). Any bills, physicians’ reports or receipts should be attached. In the case of payment due to the death of a member, a photocopy of the death certificate must be attached. A separate voucher must be filled out for each claimant. Original bills may substitute for the signature of the payee for medical claims. All other claims must be signed by the payee and all claims must be approved by the local board of trustees before being submitted to the state board for payment.

This download gives a brief description of the benefits available from the Board for Volunteer Firefighters & Reserve Officers.

After submitted, this form will be presented at the next scheduled meeting of the State Board. Please inquire after that date about approval. 

These conversion tables can be used to figure out the monthly payment for retired volunteers.

This form must be submitted with documentary evidence when proving service for a member. 

This letter can be used by the local board of trustees to request reports and chart notes from medical providers. Medical records may need to be requested to determine the validity of injury claims. 

These links can be used to search for CPT codes:

http://www.myhealthscore.com/consumer/phyoutcptsearch.htm

https://catalog.ama-assn.org/Catalog/cpt/cpt_search.jsp?locality=WA

This link can be used to search for diagnosis codes:

http://www.findacode.com/icd9-diagnosis-codes.html 

MUST BE PRINTED ON  LEGAL SIZE (8 1/2" x 14") PAPER.

This form is used to report all members at the beginning of each year and to report new members as they join the department during the year. In the proper columns, it should contain the social security numbers, names, date of birth, gender, and amount of money for each member reported. All lists should be in alphabetical order by municipality and not by individual stations within a municipality. Please send the original form to the State Board on 14 inch paper and save the completed form in the computer and a paper copy in a file for future reference. 

MUST BE PRINTED ON  LEGAL SIZE (8 1/2" x 14") PAPER.

This form is used to report all members at the beginning of each year and to report new members as they join the department during the year. In the proper columns, it should contain the social security numbers, names, date of birth, gender, and amount of money for each member reported. All lists should be in alphabetical order by municipality and not by individual stations within a municipality. Please send the original form to the State Board on 14 inch paper and save the completed form in the computer and a paper copy in a file for future reference. 

MUST BE PRINTED ON  LEGAL SIZE (8 1/2" x 14") PAPER.

This form must be completed before any claims resulting from an accident can be paid by the State Board. All sections must be filled out and signed. A signed emergency room report may be attached in place of the doctor’s report.

This form is a sample of the minimum physical examination recommended by the State Board for new members. The State Board will pay one hundred dollars toward each physical examination performed when the invoice voucher requesting payment and the proof of such exam is received. Because of confidentiality concerns, this form is not to be returned to the State Board.

DOWNLOAD AVAILABLE (MS WORD) This document will print on 8 1/2" X 11" paper.

DOWNLOAD AVAILABLE (MS WORD) This document will print on 11" X 14" paper.

This form is a sample of the minimum physical examination recommended by the State Board for new members. The State Board will pay one hundred dollars toward each physical examination performed when the invoice voucher requesting payment and the proof of such exam is received. Because of confidentiality concerns, this form is not to be returned to the State Board.

DOWNLOAD AVAILABLE (MS WORD) This document will print on 8 1/2" X 11" paper.

DOWNLOAD AVAILABLE (MS WORD) This document will print on 11" X 14" paper.

Partially completed retirement forms will be sent to the department or the retiring member by the State Board upon request. The Certificate of Eligibility must be completed and approved by the Local Board of Trustees and the Notice of Retirement must be completed by the member with his or her signature notarized. After both forms are returned to the State Board, the retiree will be placed on the payroll as soon as she or he is eligible to begin receiving a pension.

We encourage retirees to have their pension deposited directly to their banking accounts. A form to activate this option will be sent with retirement forms.