Labor Lease Transaction Claims
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Labor Lease Transaction Claims Form. This is a Ohio form and can be use in Employers Workers Comp.
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Tags: Labor Lease Transaction Claims, PEOAC-19, Ohio Workers Comp, Employers
Labor Lease Transaction Claims
Prepared by:
Phone number:
Professional employer
organization (PEO) policy number:
PEO name:
Client policy number:
Client name:
Claims for lease agreement effective date:
Claim number
PEO signature
Manual number
Date
Claimant name (please print)
Title
Change in lease agreement
Termination of lease agreement
Date of injury
Date
(Signature is required to indicate the above information is true to the best of your knowledge.)
BWC-0520 (Rev. 12/06/2010)
AC-19
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