Final Statement Of Account Of Compensation Paid {LIBC-392A}

DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS222 COMPENSATION FINAL STATEMENT OF ACCOUNT OF COMPENSATION PAID002 - - EMPLOYEE First name Address Address NOTICE: - - EMPLOYER Address Address INSURER or THIRD PARTY ADMINISTRATOR (if self-insured)Address Address Contact Rate From Date To Date #Wks #Days Total $ -- -- $ $ -- -- $ -- -- TOTAL COMPENSATION PAID $ American LegalNet, Inc. www.FormsWorkFlow.com -- Employer Information Claims Information Services Email Services Hearing Impaired *392A*002 Auxiliary aids and services are available upon request to individuals with disabilities.002 Equal Opportunity Employer/Program002 American LegalNet, Inc. www.FormsWorkFlow.com