COMPLETE THIS AFFIDAVIT AND
AFFIDAVIT for TIME-LOSS
RETURN TO:
COMPENSATION
Department of Labor and Industries
Division of Insurance Services
Claim Number
PO Box 44291
Olympia WA 98504-4291
Name (Please Print)
Due to my work-related injury/illness, I didn’t work and I wasn’t able to work from ___________
to ____________.
Check one box on each line to complete the statements below:
I have
been self-employed during this period.
have not
I have
have not
performed any work, paid or unpaid, including but not
limited to COPES or CHORE Services, or volunteer work,
due to a work-related injury/illness.
I have
have not
applied for or received unemployment benefits during this
period.
I have
have not
received Social Security benefits during this period.
I have
have not
applied for or received benefits from DSHS during this
period.
I have
have not
been convicted of a crime and under sentence at any time
during this period.
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 contact 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, if the
custody of my children changes, and if I apply for or receive Social Security benefits or DSHS
benefits.
Signature
Date
MAILING Address
RESIDENCE Address:
City
State
ZIP
City
State
ZIP
Residence is the same as MAILING address:
Yes
No
F242-395-000 affidavit for time-loss compensation 01-2009