LWC-WC-1025.EE
REVISED 07/2008
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.
