DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS222 COMPENSATION EMPLOYEE222S REPORT OF (UNEMPLOYMENT COMPENSATION, SOCIAL SECURITY [OLD AGE], SEVERANCE AND PENSION BENEFITS) BENEFITS FOR OFFSETS EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER - - EMPLOYEE First name Last name Date of birth Address Address City/Town State ZIP County Telephone READ THE INSTRUCTIONS ON THE REVERSE SIDE BEFORE COMPLETING THIS FORM. Section 204 of the Workers222 Compensation Act requires receipt of unemployment compensation, social security COMPLETE AND RETURN THIS FORM TO THE INSURER OR SELF-INSURED EMPLOYER IDENTIFIED ON THIS FORM. DATE OF INJURY WCAIS CLAIM NUMBER - - MM DD YYYY EMPLOYER 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 RECEIPT BEGAN RECEIPT ENDEDTYPE OF AMOUNT RECEIVED FREQUENCY DATE DATEBENEFIT (MM/DD/YYYY) (MM/DD/YYYY) Unemployment Gross $ . Weekly Biweekly002 Compensation002 Net $ . Other / / / / Gross $ . Weekly Biweekly002 (old age)002 Social Security Net $ . Other / / / Biweekly Severance Net $ . Other / / / / Gross $ . Weekly BiweeklyPension Net $ . Other / / / / % Percentage unknown (OVER) American LegalNet, Inc. www.FormsWorkFlow.com I verify that this information is true and correct, based upon my knowledge, information and belief. I understand false statements DATE Employee signature -- MM DD YYYY If you are receiving any wages from employment or self-employment, check this box . You must report this to your insurer or INSTRUCTIONS002 TO EMPLOYEES: , you must report the receipt of the following: FAILURE TO REPORT THE RECEIPT OF OR CHANGES TO ANY OF THE BENEFITS LISTED ABOVE MAY SUBJECT YOU TO PROSECUTION UNDER ARTICLE XI OF THE WORKERS222 COMPENSATION ACT RELATING TO INSURANCE FRAUD. Employer Information Claims Information Services Email Services Hearing Impaired *756*002 Auxiliary aids and services are available upon request to individuals with disabilities.002 Equal Opportunity Employer/Program002 American LegalNet, Inc. www.FormsWorkFlow.com