Authorization For Alternative Delivery Of Compensation Payments {LIBC-10}

DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS222 COMPENSATION AUTHORIZATION FOR 002ALTERNATIVE DELIVERY OF COMPENSATION PAYMENTS002 EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER -- WCAIS CLAIM NUMBER --DATE OF INJURY EMPLOYEE First name Last name Date of birth Address Address City/Town State ZIP County Telephone DATE OF AUTHORIZATION - - MM DD YYYY MM DD YYYY EMPLOYER Name Address Address City/Town State ZIP County Telephone FEIN INSURER or THIRD PARTY ADMINISTRATOR (if self-insured) Name Address Address City/Town State ZIP County Telephone FEIN Contact NAIC code or Insurer code Insurer/TPA claim # I, , hereby authorize and agree that the checks for the compensation payments due Claimant name (please print) to me shall be forwarded to me in the following designated manner: The employer/insurer will mail my checks to me at: Other: American LegalNet, Inc. www.FormsWorkFlow.com I understand that my employer/insurer is required to mail my compensation checks to my last known address and that I am not under any obligation to authorize the method of delivery outlined above. (typed/printed) (typed/printed) Employer Information Claims Information Services Email Services Hearing Impaired *10*002 Auxiliary aids and services are available upon request to individuals with disabilities.002 Equal Opportunity Employer/Program002 American LegalNet, Inc. www.FormsWorkFlow.com