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The document is a Wage Loss Statement for injured workers seeking compensation while searching for jobs. It outlines the process for reporting earnings, job search activities, and required verifications. Workers must complete the form weekly, report all income from any work activity, and provide detailed information about job contacts. Failure to complete the form accurately may lead to reduced benefits. The document also includes a warning about the consequences of providing false information.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your name and the week for which you are requesting wage loss compensation. Ensure that you have your claim number ready.
In the earnings section, indicate whether you received any income during this period. If yes, specify the amount and type of work activity.
Fill in the details of each job contact, including employer name, address, and description of the job applied for. Be thorough to avoid any issues with benefit payments.
Select your method of contact and indicate if you filled out an application or were granted an interview. This information is crucial for verification purposes.
Review all entries for accuracy before submitting. Attach any required documentation, such as email confirmations or pay stubs.

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