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.

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.

Used by employers with no employees or worker hours to report but need an open account for contract bidding process.

Crime Victim Worker Verification - Spanish - Formulario de Verificación de Empleo

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.

State fund workers who have selected Option 2 and closed their claim can use this form to apply for access to their Option 2 training funds. To seek reimbursement, use form F245-030-000 Statement for Retraining and Job Modification Services.

Used by the student and a school official each quarter to verify school enrollment.

Use by the student and a school official each quarter to verify school enrollment.

For use by crime victims requesting time-loss compensation

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.