Washington > Workers Comp > Self Insurance
Housing And Board Cost Encumbrance F245-372-000 - Washington
| Housing And Board Cost Encumbrance Form. This is a Washington form and can be used in Self Insurance Workers Comp . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
Department of Labor and Industries This form must be completed by the Vocational Counselor assigned by either State Fund or Self Insurance. HOUSING & BOARD COST ENCUMBRANCE Original Date **** Counselor is responsible for sending a copy of this form to each vendor **** Claimant: Vendor Name Vendor Name Revised Claim Number Vendor Name Modification Vendor Name Total Funds Billing Category and Code Board - R0360 (Food & Utilities) Provider No. Provider No. Provider No. Provider No. (Room & Furniture) Housing - R0370 Relocation - 0375R (1 time/life of claim) Vendor Funds Allocated Dates of Service From: To: From: To: From: To: From: To: NOTICE: 1) Please attach an approved copy of this form to the F245-030-000 Statement for Retraining and Job Modification Services form (pink) when submitting bill(s). 2) Per Diem for Housing - RO370 is calculated for the County in which the training site is located. 3) When billing includes refundable cleaning fees and/or start-up fees, the vendor(s) is/are reminded that any/all of the refund is to be returned to the Department of Labor and Industries or to the self insurer. Please include a copy of this form with your refund. Refund Mailing Addresses: State Fund Claims: ATTN: Cashiers Office Department of Labor and Industries PO Box 44835 Olympia WA 98504-4835 Self Insured Claims (to be provided by Insurer): Company Assigned Vocational Counselor: Phone No. Date Signature FAX No. For Dept. Use Only Vocational Services Specialist Not Approved Approved Date Phone No. Signature F245-372-000 housing and board cost encumbrance 01-2008 For workers with training plans approved before 1-1-2008, use form F245-355-000 INDEX: VPLAN American LegalNet, Inc. www.FormsWorkFlow.com
|
|||||||
