First 52 Week Period Board And Room Cost Encumbrance
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First 52 Week Period Board And Room Cost Encumbrance Form. This is a Washington form and can be use in Claims Workers Comp.
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Tags: First 52 Week Period Board And Room Cost Encumbrance, F245-355-000, Washington Workers Comp, Claims
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1st 52 WEEK PERIOD
Department of Labor and Industries
This form must be completed by the Vocational
Counselor assigned by either State Fund or
Self Insurance.
BOARD & ROOM COST ENCUMBRANCE
Modification
Original
**** Counselor is responsible for sending
a copy of this form to each vendor ****
Claimant:
Date
Vendor Name
Vendor Name
Vendor Name
Claim Number
Vendor Name
Total
Funds
Billing Category
and Code
Provider No.
Provider No.
Provider No.
Provider No.
From:
To:
From:
To:
From:
To:
From:
To:
Board - R0360
(Food & Utilities)
Housing - R0370
(Room & Furniture)
Relocation - 0375R
(1 time/life of claim)
Vendor Funds
Allocated
Dates of Service
NOTICE:
1) Please attach an approved copy of this form to the F245-030-000 Statement for Retraining and Job
Modification Services form (pink) when submitting bill(s).
2) Per Diem for Housing - RO370 is calculated for the County in which the training site is located.
3) When billing includes refundable cleaning fees and/or start-up fees, the vendor(s) is/are reminded that
any/all of the refund is to be returned to the Department of Labor and Industries or to the self insurer.
Please include a copy of this form with your refund.
Refund Mailing Addresses:
State Fund Claims:
ATTN: Cashiers Office
Department of Labor and Industries
PO Box 44835
Olympia WA 98504-4835
Company
Self Insured Claims (to be provided by Insurer):
Phone No.
Assigned Vocational Counselor:
Date
FAX No.
Signature
For Dept. Use Only
Vocational Services Specialist
Approved
Date
Phone No.
Signature
Not
Approved
F245-355-000 1st 52 wk bd & rm cost encumbrance 01-2008
For workers with training plans approved after 1-1-2008, use form F245-372-000
INDEX: VPLAN
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