Get Statutory Counter Offer Form

Filling out the Statutory Counter Offer Form is an essential process for workers and employers involved in compensation claims. This guide will provide you with detailed steps to help you successfully complete the form online.

Follow the steps to effectively complete the form.

1. Click 'Get Form' button to obtain the form and open it in the editor, allowing you to access the necessary fields.
2. Begin filling in the 'Worker' section by entering the name of the individual who is submitting the counter offer. Make sure to include the full legal name of the worker.
3. In the 'Employer' field, provide the name of the employing organization or entity. This should reflect the registered name of the employer.
4. If applicable, enter the name of the 'Self-Insurer' in the designated field. Ensure this is completed only if the employer is self-insured.
5. Date the application by entering the date of the worker's application under Section 134AB / Section 328. This is critical for establishing the timeline of your claim.
6. Now, move to the 'Statutory counter offer' section. Specify the amount being offered numerically in the 'Figure' field and also write it out in words in the provided space.
7. Complete the field for the 'Worker’s legal representative' if there is one; otherwise, fill out the 'Worker' section with their name if they are not represented.
8. Finally, fill in the date on which you are completing this form to ensure all provided information is current.
9. Once you've carefully reviewed all entered details for accuracy, you can save your changes, download, print, or share the form as needed.

Compete your documents online to ensure timely and efficient processing of your statutory counter offer.