New Hampshire > Workers Comp > General
Request For Job Modification Plan Approval - New Hampshire
| Request For Job Modification Plan Approval Form. This is a New Hampshire form and can be used in General Workers Comp . |
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State of New Hampshire Department of Labor David M. Wihby Acting Labor Commissioner State Office Park South 95 Pleasant Street Concord, NH 03301 603/271-3176 TDD Access: Relay NH 1-800-735 -2954 FAX: 603/271-6149 REQUEST FOR JOB MODIFICATION PLAN APPROVAL EMPLOYEE NAME:___________________________________SSN:________________DOI:___________ EMPLOYER NAME:______________________FEIN:________________TELEPHONE:________________ EMPLOYER ADDRESS:__________________________________________________________________ DESCRIPTION OF EMPLOYEE'S IMPAIRMENT WITH ATTACHED MEDICAL RELEASE TO RETURN TO WORK OR WITH ANTICIPATED RELEASE DATE: DESCRIBE THE SPECIFIC JOB MODIFICATIONS: PROPOSED COSTS FOR MATERIALS, EQUIPMENT, AND LABOR WITH ESTIMATES: DATE SUBMITTED:________________________ SUBMITTED BY:__________________________ TITLE___________________________________ Send check to: Attention _________________________________ _________________________________________ _________________________________________ _________________________________________ _____APPROVED _____NOT APPROVED _______________________________________ DEPARTMENT REPRESENTATIVE DATE American LegalNet, Inc. www.FormsWorkFlow.com
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