North Dakota > Workers Comp
Employment Contact Log SFN 54198 - North Dakota
| Employment Contact Log Form. This is a North Dakota form and can be used in Workers Comp . |
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EMPLOYMENT CONTACT LOG RETURN TO WORK DIVISION SFN 51498 (05/2008) 1600 EAST CENTURY AVENUE, SUITE 1 PO BOX 5585 BISMARCK ND 58506-5585 TELEPHONE 1-800-777-5033 Toll Free Fax 1-888-786-8695 TTY (hearing impaired) 1-800-366-6888 Fraud and Safety Hotline 1-800-243-3331 www.WorkforceSafety.com Injured Worker's Name Claim Number Date Injured Worker's Address INSTRUCTIONS Injured worker: Please print or type using black or blue ink. Return this form at least once per month, or sooner if it is completed, to: WORKFORCE SAFETY & INSURANCE (WSI) PO BOX 5585 BISMARCK ND 58506-5585 FRAUD WARNING: By signing this form, I acknowledge that I have read the Fraud Warning on the reverse side of this form and understand that falsifying this claim or making a false statement regarding this claim may be a felony punishable by substantial fines and imprisonment. By my signature below, I declare that the statements on this form are true and accurate. CONTACT 1 Contact Date Employer & Address Yes Yes Yes No No No Contact Person & Telephone Type of Job Results: Hiring Application Interview Type of Contact In Person Telephone Follow Up & Date Outcome & Comments CONTACT 2 Contact Date Employer & Address Yes Yes Yes No No No Contact Person & Telephone Type of Job Results: Hiring Application Interview Type of Contact In Person Telephone Follow Up & Date Outcome & Comments CONTACT 3 Contact Date Employer & Address Yes Yes Yes No No No Contact Person & Telephone Type of Job Results: Hiring Application Interview Type of Contact In Person Telephone Follow Up & Date Outcome & Comments CONTACT 4 Contact Date Employer & Address Yes Yes Yes No No No Contact Person & Telephone Type of Job Results: Hiring Application Interview Type of Contact In Person Telephone Follow Up & Date Outcome & Comments CONTACT 5 Contact Date Employer & Address Yes Yes Yes No No No Contact Person & Telephone Type of Job Results: Hiring Application Interview Type of Contact In Person Telephone Follow Up & Date Outcome & Comments CONTACT 6 Contact Date Employer & Address Yes Yes Yes No No No Contact Person & Telephone Type of Job Results: Hiring Application Interview Type of Contact In Person Telephone Follow Up & Date Outcome & Comments CONTACT 7 Contact Date Employer & Address Yes Yes Yes No No No Contact Person & Telephone Type of Job Results: Hiring Application Interview Type of Contact In Person Telephone Follow Up & Date Outcome & Comments Injured Worker's Signature Date American LegalNet, Inc. www.FormsWorkFlow.com FRAUD WARNING - PENALTY FOR FILING FALSE CLAIMS WITH WORKFORCE SAFETY & INSURANCE (WSI) Any person claiming benefits or compensation from WSI who files a false claim, or makes a false statement, or fails to notify WSI as to the receipt of income or an increase in income from employment, in connection with any claim or application for workers compensation benefits will FORFEIT ANY FUTURE BENEFITS and may be GUILTY OF A FELONY which is punishable by IMPRISONMENT, SUBSTANTIAL FINES, OR BOTH. These criminal penalties are applicable to ALL PERSONS dealing with the Fund, including INJURED WORKERS, EMPLOYERS, MEDICAL PROVIDERS, AND ATTORNEYS. I ACKNOWLEDGE, by my signature on the front of this form, THAT I HAVE READ AND UNDERSTAND THE ABOVE DESCRIPTION OF THE PENALTIES FOR SUBMITTING A FALSE CLAIM FOR BENEFITS OR MAKING FALSE STATEMENTS TO WSI. I understand that WSI is relying upon the truth of my statements in awarding benefits or providing services on this claim. I CERTIFY THAT I HAVE NOT FILED A FALSE CLAIM, NOR MADE ANY FALSE STATEMENT, NOR KNOW OF ANY FALSE STATEMENT, MADE IN CONNECTION WITH THIS CLAIM FOR BENEFITS WITH WSI. American LegalNet, Inc. www.FormsWorkFlow.com
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