Wage Loss Statement For Job Search {BWC-1268} | Pdf Fpdf Doc Docx | Ohio

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Wage Loss Statement For Job Search {BWC-1268} | Pdf Fpdf Doc Docx | Ohio

Wage Loss Statement For Job Search {BWC-1268}

This is a Ohio form that can be used for Injured Workers within Workers Comp.

Alternate TextLast updated: 9/18/2006

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<document>COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.WAGE LOSS STATEMENT FOR JOB SEARCHCalendar No.JUDICIAL SUBPOENAPlaintiff(s)Job search for week of Injured worker name INSTRUCTIONS: Use this form when requesting wage loss compensation.-against- Complete this form weekly. More than one form may be used for each week. Submit or mail your forms no less than every four weeks to your local customer service specialist. If your employer is a self-insuring employer, mail your completed form(s) to your self-insuring employer.Fromto Claim number Better Workers' Compensation Built with you in mind.If yes, amount of earnings received $ Have you received earnings from working during this period? YesNoWeeklyMonthlyHourly1Telephone numberName of employerDefendant(s). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CityStateZIP codeDescription of job for which you applied/obtainedDate of contact AddressTHE PEOPLE OF THE STATE OF NEW YORK TOMethod of contactResult of contactYesNoRegular mailHired Contact personWill callIn person E-mailNot presently hiringWere you granted an interview? Did you fill out an application?Interview scheduledSubmitted resume' TelephoneFaxOtherYesNo2Name of employerTelephone numberCityStateZIP codeGREETINGS:Description of job for which you applied/obtainedDate of contact AddressWE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,Method of contactResult of contactlocated at County ofYesNoWill callRegular mailHired Contact personIn person E-mailNot presently hiringo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the partOtherof thenoon, and at any recessed in roomWere you granted an interview? Did you fill out an application?Interview scheduledSubmitted resume' TelephoneFaxYesNo3Name of employerTelephone numberCityZIP codeStateYour failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.Description of job for which you applied/obtainedContact personDate of contact AddressMethod of contactResult of contactYesNoWill callRegular mailHiredIn person E-mailNot presently hiring, one of the Justices of theWere you granted an interview? Did you fill out an application?Interview scheduledSubmitted resume' TelephoneFaxOtherNoYesCourt in Witness, Honorableday of, 20 County,4Name of employerTelephone numberCityAddressZIP codeState(Attorney must sign above and type name below)Description of job for which you applied/obtainedDate of contactContact personDid you fill out an application?Method of contactResult of contactAttorney(s) forNoYesWill callRegular mailHiredIn person E-mailNot presently hiringWere you granted an interview?Interview scheduledSubmitted resume' TelephoneFaxOtherNoYes5Name of employerTelephone numberCityAddressZIP codeStateOffice and P.O. AddressDescription of job for which you applied/obtainedDate of contactContact personTelephone No.: Facsimile No.: E-Mail Address:Did you fill out an application?Method of contactResult of contactNoYesTelephoneWill callRegular mailHiredIn person E-mailNot presently hiringWere you granted an interview?Interview scheduledSubmitted resume'FaxOtherNoYesMobile Tel. No.:BWC-1268 (Rev. 9/5/2000) C-141American LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.6Name of employerTelephone numberCalendar No.CityStateZIP codeJUDICIAL SUBPOENADescription of job for which you applied/obtainedDate of contact AddressPlaintiff(s)-against-Method of contactResult of contactYesNoWill callHired Contact personRegular mailIn person E-mailNot presently hiringWere you granted an interview? Did you fill out an application?Interview scheduledSubmitted resume' TelephoneFaxOtherYesNo7Telephone numberName of employerCityStateZIP codeDefendant(s). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Description of job for which you applied/obtainedDate of contact AddressMethod of contactResult of contactYesNoRegular mailHired Contact personWill callIn person E-mailNot presently hiringTHE PEOPLE OF THE STATE OF NEW YORK TOWere you granted an interview? Did you fill out an application?Interview scheduledSubmitted resume' TelephoneFaxOtherYesNo8Name of employerTelephone numberCityStateZIP codeGREETINGS:Description of job for which you applied/obtainedDate of contact AddressMethod of contactResult of contactWE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the HonorableYesNoWill callRegular mailHired Contact personIn person E-mailNot presently hiring,Were you granted an interview? Did you fill out an application?Interview scheduledSubmitted resume' TelephoneFaxlocated at County ofOtherYesNoo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon,Telephoneand at any recessed inemployerroom9Name ofnumberCityZIP codeStateDescription of job for which you applied/obtainedContact personDate of contact AddressYour failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for aanmaximum penalty of $50 and all damages sustained as a result of your failure to comply.application?Method of contactResult of contactYesNoWill callRegular mailHiredIn person E-mailNot presently hiringWere you granted an interview? Did you fill outInterview scheduledSubmitted resume' TelephoneFaxOtherYesNo10Name of employerTelephone number, one of the Justices of theCourt in Witness, Honorableday of, 20 County,CityZIP codeStateDescription of job for which you applied/obtainedDate of contact AddressContact person(Attorney must sign above and type name below)Method of contactResult of contactNoYesWill callRegular mailHiredIn person E-mailNot presently hiringWere you granted an interview? Did you fill out an application?Interview scheduledSubmitted resume' TelephoneFaxOtherNoYesAttorney(s) forSignatureDate Iherebycerti

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