Worker Verification Form

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Department of Labor and Industries
Claims Section
PO Box 44291
Olympia WA 98504-4291
Claim number
Date of request
Date of injury
Complete this form so we can consider paying time loss benefits.
Instructions to worker:
If you can’t work
due to your workplace injury or disease AND your employer is not paying your full wages: 1) Fill out this form.
2) Sign and date it. 3) Mail it to the address above within 14 days.
Phone Number
Fill in ONLY if you have a new
address and/or phone number.
Worker’s Statement
Due to my work-related injury/illness, I didn't work, and I wasn't able to work from ________ to _________
This means you didn't perform any type of work – paid or unpaid – such as volunteer work, self-employment,
COPES or CHORE Services. Please DON'T include the last date worked in the range above.
I am now working _______ Hours per day _______ Days per week
I will/did return to work on
My current wage is: $________ per
I have applied for the
Food stamps only
Retirement benefits
following benefits:
Social Security benefits
Other public assistance
On the date of injury, was your employer paying any part of your and/or your family’s medical, dental and/or vision
insurance benefits, or providing housing, board and/or fuel (utilities)?
Are you still receiving these benefits?
No, last date covered ________________
By signing below, I certify under penalty of perjury under the laws of the state of Washington that the foregoing is
true and correct and further that: 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 #
Worker’s name (please print)
Worker’s signature
242-052-000 worker verification form 10-2008


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Parent category: Legal