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Make name/address corrections above OMISSION OF THE ABOVE APPLICABLE INFORMATION CONSTITUTES AN INCOMPLETE RETURN USE BLACK INK ONLY ON THIS FORM 1. NUMBER OF EMPLOYEES REPORTED This includes employees sole proprietor and partners. 2. AMOUNT DUE 3. PENALTY AND INTEREST IS 6 PER MONTH IF APPLICABLE Penalty per Month 5 0. 05 Maximum 50 Interest per Month 1 0. 01 4. TOTAL PAYMENT THIS QUARTER - ADD LINES 2 3 Make check payable to TREASURER CITY OF PITTSBURGH DO NOT SEND CASH Mail to CITY TREASUR ...

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Versions	Form popularity	Fillable & printable
2022	4.8 Satisfied (49 Votes)
2021	4.4 Satisfied (157 Votes)
2020	4.3 Satisfied (201 Votes)
2014	4 Satisfied (25 Votes)
2016	4.1 Satisfied (46 Votes)
2017	4.2 Satisfied (73 Votes)

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What is the name of the form that authorizes the physician to treat the employee?

Overview: The Request for Authorization for Medical Treatment (DWC Form RFA) is required for the employees treating physician to initiate the utilization review process required by Labor Code section 4610.

Which is an example of an on the job injury?

If you get hurt on the job, your employer is required by law to pay for workers compensation benefits. You could get hurt by: One event at work. Examples: hurting your back in a fall, getting burned by a chemical that splashes on your skin, getting hurt in a car accident while making deliveries.

When an employee is injured on the job most states require?

Typically an injured employee is required to provide written notice, and most states set deadlines for reporting injuries. For example, the employer must be notified within 30 days in New York, while other states allow employees a year or more to report an injury.

What is a LS form?

The LS-200 form is the report of earnings form that the employer carrier will send to claimants to provide their earnings including self employment earnings. The form must be returned within 30 days or the employer carrier may terminate benefits.