EMPLOYEE CERTIFICATE OF COMPLIANCE You must submit this form to your employer's workers' compensation insurer or to your employer within 14 days of its receipt. Your workers' compensation benefits may be suspended if you do not timely submit this Certification. You would be entitled to all suspended benefits after this Certification is provided to your insurer, if you are otherwise eligible for benefits. It is unlawful for you to work and receive workers' compensation disability benefits, except for supplemental earnings benefits. Supplemental earnings benefits are paid when an employee is able to work, but is unable to earn 90% or more of his pre-injury wages as a result of a job related accident. As an injured worker, you must notify your employer or insurer of the earning of any wages, changes in employment or medical status, receipt of unemployment benefits, receipt of social security benefits and receipt of retirement benefits. If you receive benefits for more than 30 days, you will be required to certify your earnings to your insurer quarterly. It is unlawful for you to receive workers' compensation indemnity disability benefits and unemployment benefits at the same time, except for permanent partial disability benefits. Permanent partial disability benefits are paid solely for amputation or for anatomical loss of use of a body part or function. If you violate this provision, you may be fined up to $10,000, imprisoned up to 90 days, or both. It is unlawful for you to willfully make, or to assist or counsel someone else to make, a false statement or representation in order to obtain or to defeat workers' compensation benefits. If you violate this provision, you may be fined, imprisoned, or both, as follows: Unlawful Benefits Paid or Claimed $10,000 or more $2,500 or more but less than $10,000 less than $2,500 Fine up to $10,000 Imprisonment up to 10 years, with or without hard labor up to $ 5,000 up to $500 up to 5 years, with or without hard labor up to 6 months In addition to these criminal penalties, you may be assessed a civil penalty of up to $5,000 and may forfeit your right to receive workers' compensation benefits. EMPLOYEE CERTIFICATION I certify that I understand the contents of this entire document, and that I understand I am held responsible for this information. I certify my compliance with the above stated requirements regarding receipt of workers' compensation benefits. Print Name Signature Social Security Number ( Date Address City State / Zip ) Phone Number Note: Only one copy is required per case from the employee. Please mail this form to your employer or your employer's insurer. American LegalNet, Inc. www.FormsWorkflow.com LWC-WC-1025.EE REVISED 07/2008