Eligibility Certification Form | Pdf Fpdf Docx | Delaware

 Delaware   Workers Compensation 
Eligibility Certification Form | Pdf Fpdf Docx | Delaware

Last updated: 8/21/2023

Eligibility Certification Form

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Description

ELIGIBILITY CERTIFICATION FORM. This form is used in Delaware for the Workers' Compensation Fund. It is sent to individuals who have filed a petition for a hearing before the Industrial Accident Board to request the termination of their disability benefits due to an injury. The form collects the claimant's personal information, employment status, and details about their earnings. It also requires the claimant's signature to affirm the accuracy of the provided information and the commitment to notify the Office of Workers' Compensation about any changes in employment status or personal information. The completed form should be returned to the Office of Workers' Compensation for processing. www.FormsWorkflow.com

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