Get WA F242-052-000 2008-2024

Phone Date Worker s name please print F242-052-000 worker verification form 10-2008 Worker s signature. Department of Labor and Industries Claims Section PO Box 44291 Olympia WA 98504-4291 WORKER VERIFICATION FORM Claim number Date of request Date of injury Instructions to worker Complete this form so we can consider paying time loss benefits. If you can t work due to your workplace injury or disease AND your employer is not paying your full wages 1 Fill out this form* 2 Sign and date it. 3 Mail it to the address above within 14 days. Name Phone Number Address Fill in ONLY if you have a new address and/or phone number. City State ZIP Worker s Statement Due to my work-related injury/illness I didn t work and I wasn t able to work from to This means you didn t perform any type of work paid or unpaid such as volunteer work self-employment COPES or CHORE Services. Please DON T include the last date worked in the range above. I am now working Hours per day Days per week I will/did return to work on I have applied for the following benefits My current wage is per Hour Week Unemployment Social Security benefits Day Month Food stamps only Other public assistance Retirement benefits None On the date of injury was your employer paying any part of your and/or your family s medical dental and/or vision insurance benefits or providing housing board and/or fuel utilities Yes No Are you still receiving these benefits No last date covered By signing below I certify under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct and further that I understand that if I make a false statement about my activities or physical condition I will be required to refund my benefits and I may face civil or criminal penalties. I understand I must immediately notify my claim manager if I perform any work paid or unpaid if my doctor releases me for work if I am incarcerated and under sentence or if the custody of my children changes. If you can t work due to your workplace injury or disease AND your employer is not paying your full wages 1 Fill out this form* 2 Sign and date it. 3 Mail it to the address above within 14 days. Name Phone Number Address Fill in ONLY if you have a new address and/or phone number. 3 Mail it to the address above within 14 days. Name Phone Number Address Fill in ONLY if you have a new address and/or phone number. City State ZIP Worker s Statement Due to my work-related injury/illness I didn t work and I wasn t able to work from to This means you didn t perform any type of work paid or unpaid such as volunteer work self-employment COPES or CHORE Services. City State ZIP Worker s Statement Due to my work-related injury/illness I didn t work and I wasn t able to work from to This means you didn t perform any type of work paid or unpaid such as volunteer work self-employment COPES or CHORE Services. Please DON T include the last date worked in the range above. I am now working Hours per day Days per week I will/did return to work on I have applied for the following benefits My current wage is per Hour Week Unemployment Social Security benefits Day Month Food stamps only Other public assistance Retirement benefits None On the date of injury was your employer paying any part of your and/or your family s medical dental and/or vision insurance benefits or providing housing board and/or fuel utilities Yes No Are you still receiving these benefits No last date covered By signing below I certify under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct and further that I understand that if I make a false statement about my activities or physical condition I will be required to refund my benefits and I may face civil or criminal penalties. .