Affidavit for Time Loss Compensation Benefits

Información del documento
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Título

Affidavit for Time Loss Compensation Benefits

(Un formulario electrónico)- 138 KB PDF)
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.

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
Información relacionada
Documentos

Worker Verification Form


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