Free F207-177-000 APPLICATION FOR SELF INSURANCE CLAIMS ADMINISTRATOR TEST - Washington

STATE OF WASHINGTON

DEPARTMENT OF LABOR AND INDUSTRIES
Post Office Box 44890 Olympia, Washington 98504-4890

SELF INSURANCE CLAIMS ADMINISTRATOR TEST
Application Information
In 2009, the Department of Labor and Industries will offer four testing sessions for the Self Insurance Claims Administrator Test. Applications to take this test will be accepted as follows: Test Date March 18, 2009 June 17, 2009 September 16, 2009 December 9, 2009 Applications Accepted From To December 22, 2008 February 1, 2009 March 22, 2009 May 2, 2009 June 21, 2009 August 1, 2009 September 20, 2009 October 25, 2009

Applications received outside these time frames will not be processed.
This test is intended for experienced claims adjudicators who are actively managing claims in the selfinsured community. To be eligible for taking the test, you must have a minimum of three years experience in the administration of Washington workers' compensation claims in the last five years. Describe in detail your experience managing Washington workers compensation claims in the following areas. Include your specific job duties and estimate the amount of time you spend in each area (i.e. percentage of time spent each day, each week, etc.). · · · · · · Determining claim validity Authorizing/denying medical treatment Calculating and paying indemnity benefits Authorizing vocational services Determining permanent partial disability awards Other claims management duties

Failure to include the above detailed information may result in rejection of your application. The application form begins on the following page. Please submit completed applications to: Department of Labor & Industries Self Insurance Training Unit P.O. Box 44890 Olympia, WA 98504-4890

F207-177-000 application for self insurance claims administrator test 11-2008

Department of Labor & Industries Self Insurance Section PO Box 44890 Olympia WA 98504-4890

APPLICATION FOR SELF INSURANCE CLAIMS ADMINISTRATOR TEST

This application must be completed in full and returned to the Department of Labor and Industries at the above address no less than 45 days prior to the scheduled examination date. Applicants will be notified of whether or not the requirements to take the test are met no less than 14 days prior to the scheduled examination date.
Part 1. GENERAL INFORMATION:
NAME (Last, First, Middle Initial) MAILING ADDRESS (Include apartment number, if any) CITY STATE ZIP E-MAIL ADDRESS HOME TELEPHONE WORK (or message) TELEPHONE TEST PREFERENCE (We will accommodate if possible)

Morning

Afternoon

Either

Part 2. RELEVANT WORK EXPERIENCE
Describe your experience in the administration of time loss claims under Washington State Laws (Title 51 RCW) within the past five years. Start with your present or most recent relevant employment. If you need additional space to list your relevant work experience, please provide the information in the same format as this form and attach additional page(s).
1. Present or last employer Your Title Immediate Supervisor's Name Employer's Address Months & Years Employed in this Position From / To / Employer's Phone Number Total Months Immediate Supervisor's Phone Number

Specific Duties in Detail, include estimate of percentage of time spent each day, week etc. in each area (i.e. Determining claim validity- 15%). See page one for details.

2. Present or last employer Your Title Immediate Supervisor's Name

Employer's Address Months & Years Employed in this Position From / To /

Employer's Phone Number Total Months Immediate Supervisor's Phone Number

Specific Duties in Detail, include estimate of percentage of time spent each day, week, etc. in each area (i.e. Determining claim validity ­ 15%). See page one for details.

Part 3. DATE AND SIGNATURE
TO BE ACCEPTED, YOU MUST SIGN AND DATE THIS APPLICATION All statements are true to the best of my knowledge. I understand that the Department of Labor Industries may verify the information I have provided, and that untruthful or misleading answers are cause for rejection of this application, cancellation of any certification existing at the time of discovery, and refusal of future applications to take the self insurance claims administrator test.
Date (Month/Day/Year) Signature

F207-177-000 application for self insurance claims administrator test 11-2008

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