Affidavit for Time Loss Compensation Benefits

Affidavit for Time Loss Compensation Benefits - (Forms/Publications)
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Title Affidavit for Time Loss Compensation Benefits (A fillable form - 138 KB PDF)

Completed by injured workers contending eligibility for payment of back time loss benefits for a period that exceeds six months or $25,000. Injured workers requesting benefits for current time missed from work due to a work-related injury should use the F242-052-000 Worker Verification Form.

Form number F242-395-000
Online only. See document above to download.
Keywords injured worker, time loss, time loss compensation, time-loss
Languages English , Spanish
Valid dates 01-2009
Contact information Claims for Job Injuries
Related information

Worker Verification Form

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