Washington > Workers Comp > Self Insurance
Self Insurance Vocational Services Closing Cover Sheet F207-171-000 - Washington
| Self Insurance Vocational Services Closing Cover Sheet Form. This is a Washington form and can be used in Self Insurance Workers Comp . |
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Department of Labor and Industries Self Insurance SELF INSURANCE PO Box 44892 VOCATIONAL SERVICES Olympia WA 98504-4892 CLOSING COVER SHEET Complete this form and place it on top of the closing report. Referral Type: Claim No. Plan Implementation Worker Name Date: Referral Outcome: Write in the outcome code and exact narrative for the outcome you submitted on the Department of Labor and Industries VOCU screen: Outcome Code Outcome Code Narrative: Detail of Outcome Attached Documents Job Analysis - Job of Injury Labor Market Information Job Analysis - Other RTW options Vocational Eval/Testing results Educational History Pre-Job/Job Mod Consultation Eval Work History Physical Capaciaties/Relevant Med Info Other (please list below) Job Offer Letter Payee ID/Branch Provider ID VRC Name/Signature F207-171-000 vocational closing report cover sheet 5-05 American LegalNet, Inc. www.USCourtForms.com
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