Employers Insurance Information Sheet {LIBC-500}

DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS222 COMPENSATION REMEMBER: IT IS IMPORTANT TO TELL YOUR EMPLOYER 002ABOUT YOUR INJURY002 Employer Name: IF INSURED: Date Posted: IF SOMEONE OTHER THAN INSURER IS HANDLING CLAIMS: IF SELF-INSURED IF SOMEONE OTHER THAN SELF-INSURER IS HANDLING CLAIMS: Employer Information Claims Information Services Email Services Hearing Impaired *500*002 Auxiliary aids and services are available upon request to individuals with disabilities.002 Equal Opportunity Employer/Program002 American LegalNet, Inc. www.FormsWorkFlow.com