Labor Lease Transaction Claims {BWC-0520}

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. www.FormsWorkFlow.com