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Employment History Form. This is a Washington form and can be use in Claims Workers Comp.
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Tags: Employment History Form, F242-109-000, Washington Workers Comp, Claims
Department of Labor and Industries
Claims Section
PO Box 44291
Olympia WA 98504-4291
EMPLOYMENT HISTORY FORM
Worker’s Name
Page
of
Claim Number
Employment History
Please provide your employment history for the past three years, including self-employment and volunteer work.
Please start with your most recent job and work backwards. Please list any gaps or interruptions in your work history. If you were
unemployed at any time, please explain why. Did you apply for (or receive) unemployment benefits during the time period? If yes,
what dates did you receive unemployment benefits? Did you seek employment during the time period? If no, why didn’t you seek
employment?
Please specify the MONTH and YEAR for dates. If additional space is needed, this form may be copied.
From:
To:
Month
Year
Month
Year
/
/
/
/
/
Reason for work interruption
/
Employer’s Business Name
Dates (month/year): From:
/
To:
/ _________
Wages:
$
per:
Hour
Day
Month
City, State, Zip Code
Did you receive any earnings other than wages?
No
Yes:
$
per
for:
Employer’s Phone Number
Tips
Piecework
Bonuses
Commissions
(
) ______________________________________________________
Did this employer contribute to your (or your family’s) medical, dental,
or vision insurance?
No
Yes
Schedule:
Did your employer pay or reimburse you for board, housing, fuel, or
hours per day,
days per week
other such similar items?
No
What were your job title/job duties?
Yes:
Board
Housing
Fuel
Other: ____________________
$
per
Employer’s Street Address
Employer’s Business Name
Dates (month/year): From:
/
To:
/ _________
Wages:
$
per:
Hour
Day
Month
City, State, Zip Code
Did you receive any earnings other than wages?
No
Yes:
$
per
for:
Employer’s Phone Number
Tips
Piecework
Bonuses
Commissions
(
) ______________________________________________________
Did this employer contribute to your (or your family’s) medical, dental,
or vision insurance?
No
Yes:
Schedule:
Did your employer pay or reimburse you for board, housing, fuel, or
hours per day,
days per week
other such similar items?
No
What were your job title/job duties?
Yes:
Board
Housing
Fuel
Other: ____________________
$
per
Employer’s Street Address
I certify that this information is true and correct to the best of my knowledge and belief.
Date
F242-109-000 employment history form 1-06
Signature
Index: IW
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