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Plan Time Encumbrance F245-376-000 - Washington

Plan Time Encumbrance Form. This is a Washington form and can be used in Self Insurance Workers Comp .
 Fillable pdf Last Modified 11/17/2011
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Department of Labor and Industries This form must be completed by the Vocational Counselor assigned by either State Fund or Self Insurance. RESET PLAN TIME ENCUMBRANCE Original Date of this request VRC Provider ID # VRC Phone number Firm Provider # & branch ZIP+4 Injured worker's name Street address City/State Date of injury Phone number ZIP Revised Claim number Modification **** Counselor is responsible for sending a copy of this form to each vendor **** Assigned Vocational Counselor Vocational counseling firm's name Address City/State Type of Modification Change in time frames Change in goal Change in training site Change in costs Plan Dates Requested Effective start date Change start date to Continue time loss to LEP to start on LEP to end on Other (specify) End date Early plan termination Goal Method Training site DOT # Contact person Phone L&I USE ONLY Company Assigned Vocational Counselor Phone No. Date Signature FAX No. For Dept Use Only Vocational Services Specialist Not Approved Approved Date signed Phone No. Signature F245-376-000 plan time encumbrance 01-2008 For workers with training plans approved before 1-1-2008, use form F245-353-000 INDEX: VPLAN American LegalNet, Inc. www.FormsWorkFlow.com
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