Self Insurance Training Plan Cost Encumbrance
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Self Insurance Training Plan Cost Encumbrance Form. This is a Washington form and can be use in Self Insurance Workers Comp.
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Tags: Self Insurance Training Plan Cost Encumbrance, F207-173-000, Washington Workers Comp, Self Insurance
SELF INSURANCE
Department of Labor and Industries
This form must be completed by a Vocational
Rehabilitation Counselor who has received a referral
from a self-insured employer.
**** Counselor is responsible for sending
a copy of this form to each vendor ****
TRAINING PLAN COST ENCUMBRANCE
Claimant:
Date
Vendor Name
Billing Category
and Code
Modification
Original
Vendor Name
Vendor Name
Claim Number
Vendor Name
Provider No.
Provider No.
Provider No.
Provider No.
From:
To:
From:
To:
From:
To:
Expended Funds
per RVRE:
(attach copy)
Total
Funds
From:
To:
Travel
Tuition
Books
Equip
Supplies
Child Care
Other
Vendor Funds
Allocated
»
Dates of Service
» » » » » » » » » » » » »
Total Training Funds Allocated:
NOTE:
When vendor funds are reduced, the VRC must contact vendor to:
1) Make sure all billings are submitted and paid.
2) Notify the vendor that the amount authorized will be reduced.
3) Provide the vendor with a copy of the approved modified encumbrance form.
Company
Phone No.
Assigned Vocational Counselor:
Date
Employer or Service Representative
Not
Approved
Approved
Date
Phone No.
FAX No.
Signature
Signature
F207-173-000 training plan cost encumbrance 5-05
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