Work Status Form (formerly Worker Verification Form)

Document Information
  How to complete a fillable form.
Title Work Status Form (formerly Worker Verification Form)

This form was previously called the Worker Verification Form. This is to be completed by the injured worker if they are unable to work due to a workplace injury AND their employer is not paying their full wages.


Document number F242-052-000
How to get this document
  • Order it from our Warehouse
  • Alt Language(s) Español
    Valid dates 10/2015
    Contact information Managing Injured Workers' Claims
    Websites Workers' Comp Claims

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