Employee Report Of Wages And Physical Condition {LIBC-750}

002002003002002 EMPLOYEE REPORT OF WAGESDEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS222 COMPENSATION AND PHYSICAL CONDITION EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER - - EMPLOYEE First name Last name Date of birth Address Address City/Town State ZIP County Telephone FAILURE TO COMPLETE THIS FORM MAY SUBJECT YOU TO ARTICLE XI OF THE WC ACT RELATING TO FRAUD. YOU MUST COMPLETE AND RETURN THIS FORM WITHIN 30 DAYS OF BEGINNING EMPLOYMENT OR SELF-EMPLOYMENT DATE OF INJURY WCAIS CLAIM NUMBER - - MM DD YYYY EMPLOYER Name Address Address City/Town State ZIP County Telephone FEIN INSURER or THIRD PARTY ADMINISTRATOR (if self-insured) Name Address Address City/Town State ZIP County Telephone FEIN NAIC code or Insurer code Insurer/TPA claim # 1.Are you now employed?Yes No 2.Are you now self-employed?Yes No If you answered yes to one of the questions, please complete the following: Occupation(s): 4.Has your physical condition (caused by your work injury) changed? Yes No If yes, attach medical report. 5. Is there any other information you are aware of that is relevant in determining your entitlement to, or amount of compensation? Yes No 002If yes, please explain: (OVER) American LegalNet, Inc. www.FormsWorkFlow.com 002 002 002 002 002 002002 002 002 002 002 002 002 002 002 002 002002 002 002 Name Name002 Address002 Address002 Address002 Address002 City/Town 002State ZIP City/Town State ZIP002 Period of employment: Period of employment:002 - -From - -From MM DD YYYY MM DD YYYY - -To - -To MM DD YYYY MM DD YYYY Amount of wages $ . Amount of wages $ . IF SELF-EMPLOYEDName Address From --Address MM DD YYYY City/Town State ZIP Period of employment: To -- MM DD YYYY From --MM DD YYYY Amount of wages $ . To --MM DD YYYY Amount of wages $ . I verify that this information is true and correct based upon my knowledge, information and belief. I understand false Employee First name DATE OF NOTICE Last name MM DD YYYYSignature a petition to receive workers222 compensation, to report earnings from employment or self-employment. You must complete and return EMPLOYEE IS TO RETURN THIS COMPLETED FORM TO THE INSURER OR THIRD PARTY ADMINISTRATOR SHOWN ON THE FRONT. Employer Information Claims Information Services Email Services Hearing Impaired -- *750*Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program American LegalNet, Inc. www.FormsWorkFlow.com