Affidavit for Time Loss Compensation Benefits
See also
| Document Information | ||
|---|---|---|
 Get help downloading & printing files.  How to complete a fillable form. |
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| Title |
Affidavit for Time Loss Compensation Benefits (A fillable form - 138 KB PDF)
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| Description | 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. |
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| Detail | ||
| Form number | F242-395-000 | |
| Availability | Online only. See document above to download. |
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| Keywords | injured worker, time loss, time loss compensation, time-loss | |
| Languages | English , Spanish | |
| Valid dates | 01-2009 | |
| Contact information |
Claims for Job Injuries
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| Related information | ||
| Documents | Worker Verification Form |
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