Agreement To Stop Weekly Workers Compensation Payments (Final Receipt) {LIBC-340}

002 002 002 002 002 002 002 002 002 002 002 002 DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS222 COMPENSATION AGREEMENT TO STOP002 WEEKLY WORKERS222002 COMPENSATION PAYMENTS002 FINAL RECEIPT002 EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER -- WCAIS CLAIM NUMBER --DATE OF INJURY EMPLOYEE NOTICE TO EMPLOYEE Signing this form means your weekly workers222 compensation payments will stop. YSIGN THIS FORM IF:DO NOT SIGN THIS FORM IF: MM DD YYYY EMPLOYER INSURER or THIRD PARTY ADMINISTRATOR MM DD YYYY MM DD YYYY Notice: The employer/insurance company hereby agrees that no representations have been made to the employee other than those contained in this agreement and that this complies with the Workers222 Compensation Act and Rules and Regulations. MM DD YYYY Employer Information Claims Information Services Email Services Hearing Impaired *340*Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program American LegalNet, Inc. www.FormsWorkFlow.com