LEAFLETS, PAMPHLETS, & FORMS
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Publications - Frequently Requested Forms:
Affidavit for Time Loss - Completed by the injured workers contending eligibility for payment of back time loss benefits for a period that exceeds six months or $25,000.
Travel Reimbursement Request - Bill form for use by workers to request reimbursement for authorized travel expenses.
Loss of Earning Power (LEP) Application - Completion of this form is not a guarantee of benefits. Payment of benefits will be decided by your claim manager.