EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER -- -- DATE OF INJURY WCAIS CLAIM NUMBER MM DD YYYY EMPLOYEE EMPLOYER First name Last name Date of birth Address Address City/Town State County Telephone INSTRUCTIONS TO EMPLOYEE: DO NOT RETURN THIS FORM TO THE BUREAU OF WORKERS222 COMPENSATION. COMPLETED FORM MUST BE RETURNED TO THE PARTY WHO SENT THE FORM TO YOU WITHIN 30 DAYS OF YOUR RECEIPT OF THIS FORM. IF YOU DO NOT COMPLETE AND RETURN THIS FORM TO THE PARTY WHO SENT IT TO YOU WITHIN 30 DAYS IT MAY RESULT IN A SUSPENSION OF YOUR COMPENSATION BENEFITS AS PROVIDED BY SECTION 311.1(g) OF THE WC ACT, AS WELL AS PROSECUTION FOR FRAUD UNDER ARTICLE XI OF THE WC ACT. YOU MAY BE REQUIRED TO COMPLETE AND RETURN THIS FORM EVERY SIX MONTHS. EMPLOYEE VERIFICATION OF EMPLOYMENT, SELF-EMPLOYMENT OR CHANGE IN PHYSICAL CONDITION INSTRUCTIONS TO EMPLOYEE: Section 311.1(d) of the Workers222 Compensation Act requires employees who are receiving workers222 to physical condition. 1. Are you currently employed by any employer other than the employer listed above? Yes No 2. Are you currently self-employed?Yes No 4. Has your physical condition (caused by your injury) changed?Yes No 5. Is there other information you are aware of that is relevant in determining your entitlement to, or amount of compensation?Yes No DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS222 COMPENSATION ZIP Name Address Address City/Town State ZIP County Telephone FEIN INSURER or THIRD PARTY ADMINISTRATOR (if self-insured) Name Address Address City/Town State ZIP County Telephone FEIN NAIC code or Insurer code Insurer/TPA claim # (OVER) American LegalNet, Inc. www.FormsWorkFlow.com Name Address Address City/Town State ZIP Period of employment: From To Amount of wages $ --MM DD --MM DD . YYYY YYYY Name Address Address City/Town State ZIP Period of employment: From To Amount of wages $ --MM DD --MM DD . YYYY YYYY Name Address Address City/Town State ZIP Period of employment: -- From MM DD YYYY --MM DD YYYY To Amount of wages $ . IF SELF-EMPLOYED From MM -DD -YYYY To MM -DD -YYYY Amount of wages $ . I verify that this information is true and correct based upon my knowledge, information and belief. I understand false Employee First name Last name DATE OF NOTICE -- Signature MM DD YYYY Employer Information Claims Information Services Email Services Hearing Impaired *760*002 Auxiliary aids and services are available upon request to individuals with disabilities.002 Equal Opportunity Employer/Program002 American LegalNet, Inc. www.FormsWorkFlow.com