Workers' Compensation - Employee Certificate Of Compliance printable pdf download

EMPLOYEE

CERTIFICATE OF COMPLIANCE

You must submit this form to your employer's workers' compensation insurer or to your employer within

14 days of its receipt. Your workers' compensation benefits may be suspended if you do not timely submit this

Certification. You would be entitled to all suspended benefits after this Certification is provided to your insurer, if you are

otherwise eligible for benefits.

It is unlawful for you to work and receive workers' compensation disability benefits, except for

supplemental earnings benefits. Supplemental earnings benefits are paid when an employee is able to work, but is

unable to earn 90% or more of his pre-injury wages as a result of a job related accident. As an injured worker, you must

notify your employer or insurer of the earning of any wages, changes in employment or medical status, receipt of

unemployment benefits, receipt of social security benefits and receipt of retirement benefits. If you receive benefits for

more than 30 days, you will be required to certify your earnings to your insurer quarterly.

It is unlawful for you to receive workers' compensation indemnity disability benefits and unemployment

benefits at the same time, except for permanent partial disability benefits. Permanent partial disability benefits are

paid solely for amputation or for anatomical loss of use of a body part or function. If you violate this provision, you may

be fined up to $10,000, imprisoned up to 90 days, or both.

It is unlawful for you to willfully make, or to assist or counsel someone else to make, a false statement or

representation in order to obtain or to defeat workers' compensation benefits. If you violate this provision, you

may be fined, imprisoned, or both, as follows:

Unlawful Benefits

Fine

Imprisonment

Paid or Claimed

$10,000 or more

up to $10,000

up to 10 years, with or without hard labor

$2,500 or more but less

than $10,000

up to $ 5,000

up to 5 years, with or without hard labor

less than $2,500

up to $500

up to 6 months

In addition to these criminal penalties, you may be assessed a civil penalty of up to $5,000 and may forfeit your right to

receive workers' compensation benefits.

EMPLOYEE CERTIFICATION

I certify that I understand the contents of this entire document, and that I understand I am held responsible for this

information. I certify my compliance with the above stated requirements regarding receipt of workers’ compensation

benefits.

Print Name

Signature

Social Security Number

Date

(

)

Address

City

State / Zip

Phone Number

Note:

Only one copy is required per case from the employee.

Please mail this form to your employer or your employer’s insurer.

LWC-WC-1025.EE

REVISED 07/2008

Workers' Compensation - Employee Certificate Of Compliance

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