"Eligibility Certification Form" - Delaware

Eligibility Certification Form is a legal document that was released by the Delaware Department of Labor - a government authority operating within Delaware.

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Download "Eligibility Certification Form" - Delaware

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Case File No
STATE OF DELAWARE
WORKERS COMPENSATION FUND
ELIGIBILITY CERTIFICATION FORM
The Office of Workers Compensation has received a petition for a hearing before the Industrial
Accident Board with regard to an injury that you sustained. The purpose of the petition is to
request the Board to order the termination of the disability benefits currently being paid to
you. Having filed this petition, the company will cease paying your disability benefits until the
case is heard by the Board or otherwise settled between the parties. The Office of Workers
Compensation may be obliged to continue paying your present disability benefits until the case
is heard by the Board or settled. In order for your benefits to be reinstated, you must complete
this form and return it to the Office of Workers Compensation immediately.
(Please Print)
Name________________________________________________________________________________________
Address__________________________________________________________________________________________
_________________________________________________________________________________________________
Phone number__________________________________________________________________________________
Social Security
Number______________________________________________________________________________
Employer (at the time of injury
Check one of the statements below regarding your employment status:
I have not been gainfully employed due to my industrial accident.
I have been gainfully employed effective ___________________.
Hours per week _________ Hourly rate_________ Average weekly gross wages___________
I affirm that the facts stated above are true and accurate to the best of my knowledge and belief.
I also acknowledge my responsibility to notify the Office of Workers’ Compensation
immediately if I return to gainful employment, change my employment status, change my
mailing address, or receive money from a third party action. I am aware that failure to notify
the Office of Workers Compensation of a change in employment status while receiving
Workers Compensation Fund checks may constitute fraud and result in criminal and/or civil
prosecution.
______________________________________________
Claimant signature/date
Office of Workers Compensation
Please return completed form to:
Attn:Fiscal Unit
rd
4425 N. Market Street, 3
Fl
Wilmington, DE 19802
Telephone number: (302) 761-8200
Fax number: (302) 622-4103
Document No.60-07-01-04-8/00
Case File No
STATE OF DELAWARE
WORKERS COMPENSATION FUND
ELIGIBILITY CERTIFICATION FORM
The Office of Workers Compensation has received a petition for a hearing before the Industrial
Accident Board with regard to an injury that you sustained. The purpose of the petition is to
request the Board to order the termination of the disability benefits currently being paid to
you. Having filed this petition, the company will cease paying your disability benefits until the
case is heard by the Board or otherwise settled between the parties. The Office of Workers
Compensation may be obliged to continue paying your present disability benefits until the case
is heard by the Board or settled. In order for your benefits to be reinstated, you must complete
this form and return it to the Office of Workers Compensation immediately.
(Please Print)
Name________________________________________________________________________________________
Address__________________________________________________________________________________________
_________________________________________________________________________________________________
Phone number__________________________________________________________________________________
Social Security
Number______________________________________________________________________________
Employer (at the time of injury
Check one of the statements below regarding your employment status:
I have not been gainfully employed due to my industrial accident.
I have been gainfully employed effective ___________________.
Hours per week _________ Hourly rate_________ Average weekly gross wages___________
I affirm that the facts stated above are true and accurate to the best of my knowledge and belief.
I also acknowledge my responsibility to notify the Office of Workers’ Compensation
immediately if I return to gainful employment, change my employment status, change my
mailing address, or receive money from a third party action. I am aware that failure to notify
the Office of Workers Compensation of a change in employment status while receiving
Workers Compensation Fund checks may constitute fraud and result in criminal and/or civil
prosecution.
______________________________________________
Claimant signature/date
Office of Workers Compensation
Please return completed form to:
Attn:Fiscal Unit
rd
4425 N. Market Street, 3
Fl
Wilmington, DE 19802
Telephone number: (302) 761-8200
Fax number: (302) 622-4103
Document No.60-07-01-04-8/00