Obtenga un formulario o publicación: time loss compensation
Su búsqueda de "time loss compensation" consiguió 25 resultados.
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| Título | Tipo | Número |
|---|---|---|
A Guide to Workers’ Compensation Benefits For Employees of Self-Insured Businesses
Also available in: Spanish Pamphlet/booklet: Explains to employees of self-insured businesses their rights and responsibilities under industrial insurance law. Describes benefits and how to file a claim. |
Publication | F207-085-000 |
Address Change Request for Injured Workers - (Spanish) Solicitud para Cambio de Direccion para Trabajadores Lesionados Also available in: English Completed and signed by a State Fund injured worker to notify L&I of a change in address. All address changes must be submitted in writing and signed by the injured worker. |
Form | F242-388-999 |
Affidavit for Time Loss Compensation Benefits Also available in: Spanish 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. |
Form | F242-395-000 |
Affidavit_for_Time_Loss_Compensation_Benefits (Spanish) Declaración Firmada para Compensación de Tiempo Perdido Also available in: English 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. |
Form | F242-395-999 |
Employer Verification Form - Spanish Formulario de Verificación de Empleo Also available in: English 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. |
Form | F242-052-999 |
Notificación de Decisión de Cierre para Reclamos Únicamente Médicos para Empleadores Autoasegurados Also available in: English Used by self-insured employers or their representatives, this is legal notification to an injured worker that their claim is being closed with medical benefits only. This order is used only when neither time loss compensation nor a permanent partial disability award has been paid. |
Form | F207-020-999 |
SIF-5A Cover Sheet: Wage Calculations Used by only self-insured employers and their representatives to calculate and report injured workers’ wages and time loss compensation rates. |
Form | F207-156-000 |
| Address Change Request for Injured Workers
Also available in: Spanish Completed and signed by a State Fund injured worker to notify L&I of a change in address. All address changes must be submitted in writing and signed by the injured worker. |
Form | F242-388-000 |
| Notificaci贸n de Decisi贸n de Cierre con Discapacidad Parcial Permanente para Empleadores Autoasegurados - PPD-NTL
Also available in: English Used by self-insured employers or their representatives only, this is legal notification to an injured worker that their claim is being closed. This order is used only when time loss compensation has not been paid, but a permanent partial disability award is being paid. |
Form | F207-165-999 |
| Notificaci贸n de Decisi贸n de Cierre con Discapacidad Parcial Permanente para Empleadores Autoasegurados - PPD-TL
Also available in: English Used by self-insured employers or their representatives only, this is legal notification to an injured worker that their claim is being closed. This order is used only when time loss compensation has been paid, and a permanent partial disability award is also being paid. |
Form | F207-164-999 |
| Notificaci贸n de Decisi贸n de Cierre para reclamos de Tiempo Perdido para Empleadores Autoasegurados
Also available in: English Used by self-insured employers or their representatives, this is legal notification to an injured worker that their claim is being closed. This order is used only when time loss compensation has been paid, but no permanent partial disability award is being paid. |
Form | F207-070-999 |
| Self-Insurance Report of Occupational Injury or Disease (SIF-5)
Used by only self-insured employers or their representatives to report initial time loss payments or to request interlocutory, wage, overpayment or closure orders. |
Form | F207-005-000 |
| Self-Insured Employers' Medical Only Claim Closure Order and Notice
Also available in: Cambodian, Korean, Spanish Used by self-insured employers or their representatives, this is legal notification to an injured worker that their claim is being closed with medical benefits only. This order is used only when neither time loss compensation nor a permanent partial disability award has been paid. |
Form | F207-020-111 |
| Self-Insured Employers' Medical Only Claim Closure Order and Notice - Cambodian
Also available in: English Used by self-insured employers or their representatives, this is legal notification to an injured worker that their claim is being closed with medical benefits only. This order is used only when neither time loss compensation nor a permanent partial disability award has been paid. |
Form | F207-020-666 |
| Self-Insured Employers' Medical Only Claim Closure Order and Notice - Korean
Also available in: English Used by self-insured employers or their representatives, this is legal notification to an injured worker that their claim is being closed with medical benefits only. This order is used only when neither time loss compensation nor a permanent partial disability award has been paid. |
Form | F207-020-777 |
| Self-Insured Employers' Permanent Partial Disability Closure Order and Notice - PPD-NTL
Also available in: Cambodian, Korean, Spanish Used by self-insured employers or their representatives only, this is legal notification to an injured worker that their claim is being closed. This order is used only when time loss compensation has not been paid, but a permanent partial disability award is being paid. |
Form | F207-165-000 |
| Self-Insured Employers' Permanent Partial Disability Closure Order and Notice - PPD-NTL - Korean
Also available in: English Used by self-insured employers or their representatives only, this is legal notification to an injured worker that their claim is being closed. This order is used only when time loss compensation has not been paid, but a permanent partial disability award is being paid. |
Form | F207-165-777 |
| Self-Insured Employers' Permanent Partial Disability Closure Order and Notice - PPD-NTL -Cambodian
Also available in: English Used by self-insured employers or their representatives only, this is legal notification to an injured worker that their claim is being closed. This order is used only when time loss compensation has not been paid, but a permanent partial disability award is being paid. |
Form | F207-165-666 |
| Self-Insured Employers' Permanent Partial Disability Closure Order and Notice - PPD-TL
Also available in: Cambodian, Korean, Spanish Used by self-insured employers or their representatives only, this is legal notification to an injured worker that their claim is being closed. This order is used only when time loss compensation has been paid, and a permanent partial disability award is also being paid. |
Form | F207-164-000 |
| Self-Insured Employers' Permanent Partial Disability Closure Order and Notice - PPD-TL - Cambodian
Also available in: English Used by self-insured employers or their representatives only, this is legal notification to an injured worker that their claim is being closed. This order is used only when time loss compensation has been paid, and a permanent partial disability award is also being paid. |
Form | F207-164-666 |
| Self-Insured Employers' Permanent Partial Disability Closure Order and Notice - PPD-TL -Korean
Also available in: English Used by self-insured employers or their representatives only, this is legal notification to an injured worker that their claim is being closed. This order is used only when time loss compensation has been paid, and a permanent partial disability award is also being paid. |
Form | F207-164-777 |
| Self-Insured Employers' Time Loss Claim Closure Order and Notice
Also available in: Cambodian, Korean, Spanish Used by only self-insured employers or their representatives, this is legal notification to an injured worker that their claim is being closed. This order is used only when time loss compensation has been paid, but no permanent partial disability award is being paid. |
Form | F207-070-000 |
| Self-Insured Employers' Time Loss Claim Closure Order and Notice - Korean
Also available in: English Used by only self-insured employers or their representatives, this is legal notification to an injured worker that their claim is being closed. This order is used only when time loss compensation has been paid, but no permanent partial disability award is being paid. |
Form | F207-070-777 |
| Self-Insured Employers' Time Loss Claim Closure Order and Notice -Cambodian
Also available in: English Used by only self-insured employers or their representatives, this is legal notification to an injured worker that their claim is being closed. This order is used only when time loss compensation has been paid, but no permanent partial disability award is being paid. |
Form | F207-070-666 |
| Worker Verification Form
Also available in: Spanish 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. |
Form | F242-052-000 |
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