Worker Verification Form
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1Department of Labor and Industries
WORKER VERIFICATION FORM
Claims Section
PO Box 44291
Olympia WA 98504-4291
RESET
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
I am now working
I am now working
My current wage is: $________ per
work on _________
_______ Hours/Day
_______ Days/Week
Hour
Day
Week
Month
None
Food stamps only
Social Security benefits
I have applied for the following
benefits:
Unemployment
Other public assistance programs
On the date of your 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)?
Yes
No
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
F
242-052-000 worker verification form 12-2004
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