Fillable ACKNOWLEDGEMENT OF RECEIPT OF WORKERS COMPENSATION CLAIM FORM (Taft College)

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ACKNOWLEDGEMENT OF RECEIPT OF WORKERS COMPENSATION CLAIM FORM (Taft College)

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The ACKNOWLEDGEMENT OF RECEIPT OF WORKERS COMPENSATION CLAIM FORM (Taft College) form is 1 page long and contains:

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Country of origin: US
File type: PDF

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HR/Personnel/Forms/Workers Compensation/Receive Benefits Form.doc
ACKNOWLEDGEMENT OF RECEIPT
OF WORKERS’ COMPENSATION CLAIM FORM (DWC 1)
DATE OF INJURY:
DATE OF EMPLOYER KNOWLEDGE:
I, , hereby acknowledge that I received the
Workers’ Compensation Claim Form (DWC 1) and the MPN handbook from Taft College
on , and I am requesting denying medical care.
Team Member Signature Date
Supervisor Signature Date
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ACKNOWLEDGEMENT OF RECEIPT OF WORKERS COMPENSATION CLAIM FORM (Taft College)

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Completed 2 February 2021

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