Washington > Workers Comp > Self Insurance
Training Plan Cost Encumbrance F245-374-000 - Washington
| Training Plan Cost Encumbrance Form. This is a Washington form and can be used in Self Insurance Workers Comp . |
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This form must be completed by the Vocational Counselor assigned by either State Fund or Self Insurance. **** Counselor is responsible for sending a copy of this form to each vendor **** Claimant: Vendor Name Vendor Name Department of Labor and Industries TRAINING PLAN COST ENCUMBRANCE Original Date Vendor Name Vendor Name Revised Claim Number Modification Billing Category and Code Tuition - R0310 Books - R0340 Equip - R0315 Supplies - R0312 Licensed Child Care - R0390 Other - R0350 Vendor Funds Allocated Dates of Service Provider No. Provider No. Provider No. Provider No. Expended Funds per RVRE: (attach copy) Total Funds From: To: From: To: From: To: From: To: » »»»»»»»»»»»»» Total Training Funds Allocated: NOTE: When vendor funds are reduced, the VRC must contact vendor to: 1) Make sure all billings are submitted and paid. 2) Notify the vendor that the amount authorized will be reduced. 3) Provide the vendor with a copy of the approved modified encumbrance form. Company Assigned Vocational Counselor: Phone No. Date Signature FAX No. For Dept Use Only Vocational Services Specialist Not Approved Approved Date Phone No. Signature F245-374-000 training plan cost encumbrance 01-2008 For workers with training plans approved before 1-1-2008, use form F245-354-000 INDEX: VPLAN American LegalNet, Inc. www.FormsWorkFlow.com
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