Work Status Form (formerly Worker Verification Form)

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Work Status Form (formerly Worker Verification Form)

(Un formulario electrónico)- 286 KB PDF)

This form was previously called the Worker Verification Form. This is to be completed by the injured worker if they are unable to work due to a workplace injury AND their employer is not paying their full wages.


Número del formulario F242-052-000
Disponibilidad solicítelo
Palabras claves benefits, claims, coverage, espanol, industrial insurance, occupational injuries, payment, spanish, time loss compensation, time-loss compensation, worker's compensation, workers compensation, workers' compensation
Idiomas English, Spanish
Fechas válidas 10-2015
Contacto Managing Injured Workers' Claims
Páginas de Internet Workers' Comp Claims

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