Affidavit_for_Time_Loss_Compensation_Benefits (Spanish) Declaración Firmada para Compensación de Tiempo Perdido

Affidavit_for_Time_Loss_Compensation_Benefits (Spanish) Declaración Firmada para Compensación de Tiempo Perdido - (Forms/Publications)
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Title   Affidavit_for_Time_Loss_Compensation_Benefits (Spanish) Declaración Firmada para Compensación de Tiempo Perdido (128 KB PDF)
Description

Affidavit_for_Time_Loss_Compensation_Benefits (Spanish) Declaración Firmada para Compensación de Tiempo Perdido Completed by injured workers contending eligibility for payment of back time loss benefits for a period that exceeds six months or $25,000. Injured workers requesting benefits for current time missed from work due to a work-related injury should use the F242-052-999 Worker Verification Form.

Detail
Form number F242-395-999
Availability
Online only. See document above to download.
Keywords spanish, time loss, time loss compensation
Languages Spanish , English
Valid dates 01-2009
Contact information

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