Affidavit for Time Loss Compensation Benefits
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| Información del documento | ||
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| Título |
Affidavit for Time Loss Compensation Benefits (Un formulario electrónico)- 138 KB PDF) |
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| Descripción | 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 F242-052-000 Worker Verification Form. |
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| Detalle | ||
| Número del formulario | F242-395-000 | |
| Disponibilidad | Online only | |
| Palabras claves | injured worker, time loss, time loss compensation, time-loss | |
| Idiomas | English, Spanish | |
| Fechas válidas | 01-2009 | |
| Contacto |
Claims for Job Injuries
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| Información relacionada | ||
| Documentos | Worker Verification Form |
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