[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-307725-105":53,"doc-detail-307725-en":131},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":124,"head_meta":126,"extra_data":128,"updated_unix":130},105,"en","work-status-form-li","Work Status Form - L&I","","Work Status Form is used to request time loss compensation when an individual did not work and is unable to work for dates they specify. The form must be completed within 14 days of receiving it and reviewed alongside instructions provided on the back. It collects claim number and request/injury dates, details missed or returned-to-work status (including reduced hours and types of work such as volunteer, self-employment, and caregiving), and lists benefits received plus employer-provided benefits on the injury date. 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The form should be submitted as instructed to avoid delays.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What work activities must I report on the Work Status Form?",{"text":114,"@type":110},"Report any missed time from work due to your injury, including paid and unpaid work such as volunteer activities, self-employment, or caregiving (COPES). If you returned to work, complete the return-to-work section and specify dates and type of work.",{"name":116,"@type":107,"acceptedAnswer":117},"How do other benefits affect my L&I time loss compensation?",{"text":118,"@type":110},"If you applied for or are receiving benefits such as unemployment, Social Security, or retirement, it may affect your L&I benefits. Monetary assistance from another government agency could also affect eligibility or amount.",{"name":120,"@type":107,"acceptedAnswer":121},"What happens if I sign the form with incorrect or incomplete information?",{"text":122,"@type":110},"By signing, you confirm the information is true and correct. 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If no, the last date covered:    ―    ―     \nHas the legal custody of your dependent(s) changed?  Yes  No  \n\n| Has your address or phone number changed? If so, write your new address or phone number below. |  |  |  |\n| --- | --- | --- | --- |\n|  | Name: |  |  |\n|  | Street address: |  |  |\n|  | City, state, zip code: |  |  |\n|  | Phone number: |  |  |\n\nYour signature is required below.  \nBy signing below, I certify that the information I am providing is true and correct. I understand that I must immediately notify my claim manager if my doctor releases me for any work, if I am incarcerated and under sentence, or if the custody of my children changes. I also understand that if on this form I intentionally make a false statement or fail to disclose information about my physical condition, ability to work, and/or work performed (paid or unpaid), I will be required torefund any benefits wrongfully obtained and I may be subject to civil and/or criminal penalties.  \nWorker name (please print) Worker signature Best contact phone number Date  \nF242-052-000 Work Status Form  \n09-2021  \nRESET  \nIndex: WVF  \nWork Status Form Instructions  \nThis form is for payment of time loss compensation if you didn’t work and are unable to work during the dates you indicate. It’s important you read this form carefully and complete all sections that apply to you.  \nMinimum requirements for payment of time loss compensation:  \n• Medical certification from your attending provider with objective medical findings and restrictions.  \n• A Work Status Form which you complete to request benefits.You must complete this form each time you receive it.  \nYour work status:  \n• We need to know if you missed time from any work due to your injury.  \n• It’s important to notify L&I if you’re engaged in activity that includes, but isn’t limited to volunteer work, self-employment or caregiving.  \no Volunteer work could include Red Cross, food bank, soup kitchen helper, coaching sports.  \no Self-employment could include online sales, photography, selling firewood, newspaper delivery.  \no Caregiving could include caring for disabled family, babysitting, COPES/DSHS (paid caregiving","cbCaivIkjo9b4boX","https://ap.wps.com/l/cbCaivIkjo9b4boX","pdf",1117710,"English","# Claim information\n## Dates\n## Claim number\n# Work status details\n## Missed work and return to work\n## Reduced hours or wages\n# Other benefits and employer-provided benefits\n## Unemployment, Social Security, Retirement\n## Monetary assistance from other agencies\n## Benefits provided on date of injury\n# Custody and address changes\n## Custody of dependents\n## Address or phone number changes\n# Signature","[{\"question\":\"How long do I have to complete and return the Work Status Form?\",\"answer\":\"Complete this form within 14 days each time you receive it. The form should be submitted as instructed to avoid delays.\"},{\"question\":\"What work activities must I report on the Work Status Form?\",\"answer\":\"Report any missed time from work due to your injury, including paid and unpaid work such as volunteer activities, self-employment, or caregiving (COPES). If you returned to work, complete the return-to-work section and specify dates and type of work.\"},{\"question\":\"How do other benefits affect my L\\u0026I time loss compensation?\",\"answer\":\"If you applied for or are receiving benefits such as unemployment, Social Security, or retirement, it may affect your L\\u0026I benefits. Monetary assistance from another government agency could also affect eligibility or amount.\"},{\"question\":\"What happens if I sign the form with incorrect or incomplete information?\",\"answer\":\"By signing, you confirm the information is true and correct. Intentionally making a false statement or failing to disclose information may require refunding wrongly obtained benefits and can lead to civil and/or criminal penalties.\"}]","Work Status Form - L&I | PDF",1789853860]