F242-395-999 Affidavit_for_Time_Loss_Compensation_Benefits spanish DECLARACIÓN FIRMADA PARA COMPENSACIÓN DE TIEMPO PERDIDO


F242-395-999 Affidavit_for_Time_Loss_Compensation_Benefits spanish DECLARACIÓN FIRMADA PARA COMPENSACIÓN DE TIEMPO PERDIDO

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Title	F242-395-999 Affidavit_for_Time_Loss_Compensation_Benefits spanish DECLARACIÓN FIRMADA PARA COMPENSACIÓN DE TIEMPO PERDIDO (128 KB PDF)
Description	F242-395-999 Affidavit_for_Time_Loss_Compensation_Benefits spanish DECLARACIÓN FIRMADA PARA COMPENSACIÓN DE TIEMPO PERDIDO 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 F242-052-999 Worker Verification Form.
Detail
Form number	F242-395-999
Availability	Online only
Keywords	spanish, time loss, time loss compensation
Languages	Spanish , English
Valid dates	01-2009
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