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| Description | Used to provide your employment history for the past three years, including self-employment and volunteer work. Please start with your most recent job and work backwards. Please list any gaps or interruptions in your work history. If you were unemployed at any time, please explain why. Did you apply for (or receive) unemployment benefits during the time period? If yes, what dates did you receive unemployment benefits? Did you seek employment during the time period? If no, why didn’t you seek employment? |
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| Detail | ||
| Form number | F242-109-000 | |
| Availability | Order it |
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| Keywords | claims, employment records, espanol, industrial insurance, injury, previous, spanish, work history, worker's compensation, workers compensation, workers' compensation | |
| Languages | English , Spanish | |
| Valid dates | 01-2006 | |
| Contact information |
Claims for Job Injuries
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| Web pages | Workers' Comp Claims | |
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