Final Statement Of Account Of Compensation Paid
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Final Statement Of Account Of Compensation Paid Form. This is a Pennsylvania form and can be use in Workers Comp.
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Tags: Final Statement Of Account Of Compensation Paid, LIBC-392A, Pennsylvania Workers Comp,
DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS222 COMPENSATION FINAL STATEMENT OF ACCOUNT OF COMPENSATION PAID002 - - EMPLOYEE First name Address Address NOTICE: - - EMPLOYER Address Address INSURER or THIRD PARTY ADMINISTRATOR (if self-insured)Address Address Contact Rate From Date To Date #Wks #Days Total $ -- -- $ $ -- -- $ -- -- TOTAL COMPENSATION PAID $ American LegalNet, Inc. www.FormsWorkFlow.com -- Employer Information Claims Information Services Email Services Hearing Impaired *392A*002 Auxiliary aids and services are available upon request to individuals with disabilities.002 Equal Opportunity Employer/Program002 American LegalNet, Inc. www.FormsWorkFlow.com
