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Ohio > Workers Comp > Employers

Labor Lease Transaction Claims PEOAC-19 - Ohio

Labor Lease Transaction Claims Form. This is a Ohio form and can be used in Employers Workers Comp .
 Fillable pdf Last Modified 8/23/2011
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Labor Lease Transaction Claims Prepared by: Professional employer organization (PEO) policy number: Client policy number: Claims for lease agreement effective date: Claim number Manual number Date Claimant name (please print) Phone number: PEO name: Client name: Change in lease agreement Termination of lease agreement Date of injury PEO signature Title Date (Signature is required to indicate the above information is true to the best of your knowledge.) BWC-0520 (Rev. 12/06/2010) AC-19 American LegalNet, Inc.
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