Department of Labor and Industries Claims Section PO Box 44291 Olympia WA 98504-4291 WORKER VERIFICATION FORM Unit Work Position Claim number Date of request Date of injury Instructions to worker: This is your request for time-loss compensation. This must be completed before we can consider you for benefits. If you are unable to work due to your workplace injury AND your employer is not paying your full wages: 1) Complete this form 2) Sign and date 3) Mail it to the address above within 14 days of the date you received this mailing. Name Phone number Address Fill in ONLY if you have a new address and/or phone number. City State ZIP Worker’s Statement I did not perform any work, paid or unpaid, due to a work-related injury/illness from ___________ to _____________. This includes, but is not limited to, self-employment, COPES or CHORE Services. Did you engage in other work type activities such as volunteer work? Yes No If so, please describe: _________________________________ _________________________________________________________________________________________________ I will/did return to work on _________ I am now working _______ Hours/Day I have applied for the following benefits: I am now working _______ Days/Week None Unemployment My current wage is: $________ per Hour Day Week Month Food stamps only Other public assistance programs Social Security benefits On the date of your injury, was your employer paying any part of your and/or your family’s medical, dental and/or vision Yes No insurance benefits, or providing housing, board and/or fuel (utilities)? Are you still receiving these benefits? Yes No, date coverage ended ________________ By signing below, I am certifying the following: I understand that if I make a false statement about my activities or physical condition, I will be required to refund my benefits and I may face civil or criminal penalties. I understand I must immediately notify my claim manager if I perform any work (paid or unpaid), if my doctor releases me for work, if I am incarcerated and under sentence, or if the custody of my children changes. Phone # Date Worker’s signature F242-052-000 worker verification form 12-2004 American LegalNet, Inc. www.USCourtForms.com