DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS222 COMPENSATION NOTICE OF WORKERS222002 COMPENSATION BENEFIT002 OFFSET002 EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER - - EMPLOYEE First name Last name Date of birth Address Address City/Town State ZIP County Telephone DATE OF THIS NOTICE: - - MM DD YYYY 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 County Telephone FEIN NAIC code or Insurer code Insurer/TPA claim # ATTORNEY FOR EMPLOYEE (if known) ATTORNEY FOR INSURER/EMPLOYER (if known) Name Firm name Address Address City/Town State ZIP Telephone Name Signature Address Address City/Town State ZIP Telephone FEIN Name Firm name Address Address City/Town State ZIP Telephone PA Attorney ID number A COPY OF THIS FORM AND ATTACHMENTS ARE TO BE PROVIDED TO THE EMPLOYEE AND THE EMPLOYEE222S ATTORNEY (IF KNOWN). (OVER) American LegalNet, Inc. www.FormsWorkFlow.com Compensation Act. after the end of the calendar tax year. Your offset is for the following: which is attributable to this contribution. paid: Weekly Bi-weekly Other (specify): - - MM DD YYYY - -An ending date of has been established for this offset or a portion of it to recoup prior offsetable MM DD YYYY applicable to an offset. follows and additional calculations may be attached: Attached are the following documents supporting the basis for this offset: Employer Information Claims Information Services Email Services Hearing Impaired *761*002 Auxiliary aids and services are available upon request to individuals with disabilities. American LegalNet, Inc. www.FormsWorkFlow.com