Affidavit for Time Loss Compensation Benefits

Document Information
  How to complete a fillable form.
Title Affidavit for Time Loss Compensation Benefits

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.

Document number F242-395-000
How to get this document
Alt Language(s) Español
Valid dates 01/2009
Contact information Claims for Job Injuries
Related information

Work Status Form (formerly Worker Verification Form)


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