Application for Amended Claim Resolution Settlement Agreement

Welcome to the Board of Industrial Insurance Appeals electronic filing system. Parties who have negotiated a Claim Resolution Settlement Agreement under the Washington Workers' Compensation Act (Chapter 51.04 RCW) must submit their signed settlement for approval by the Board of Industrial Insurance Appeals.

The Board's electronic filing system is designed to simplify and speed the process of approving Claim Resolution Settlement Agreement. The application sets forth the information necessary to timely process a request for approval. This is the ONLY method you may use to request approval of a Claim Resolution Settlement Agreement. Applications received by any other method will not be considered.

Public disclosure: Effective June 12, 2014, all information related to Claim Resolution Settlement Agreements submitted to the BIIA under RCW 51.04.063, other than final orders from the BIIA, is exempt from public inspection and copying under the Public Records Act. RCW 42.56.230

Customary office hours: Documents received after 5 p.m. will be deemed filed the next business day. WAC 263-12-015(3) and WAC 263-12-01501.

Warnings:
(1)You have 15 minutes to complete this form. A warning will appear with 2 minutes left. Click continue or all your data will be lost and must be reentered.
(2) You must enter an email address to receive an email confirmation of successful submission.
(3) Unless you see "Your amended claim resolution settlement agreement form has been submitted" your electronic application has NOT been received by the BIIA.
(4) This portal is only for filing amended claim resolution settlement agreements. It is applicable for those who've already filed a claim resolution settlement agreement (CRSA) and are awaiting the Board's order on the previously filed agreement. If you have not yet filed a claim resolution settlement agreement, you need to file your agreement at Application for Claim Resolution Settlement Agreement (CRSA) .

Submitter information

* indicates required field help  to display detail information
    
Your name:*  
Contact e-mail:*

Document information

BIIA Docket number:*    
Summary of changes:*
Attach document:*    
 

 
- 1 document per submission
- PDF format only
- Maximum 10Mb

By clicking 'SUBMIT' I acknowledge the records I am submitting become a public record and are subject to public disclosure under Chapter 42.56 RCW. I certify that I have removed all personally identifying information that I want to keep private or confidential (for example, social security number, bank, credit card, and other financial information defined by RCW 9.35.005).