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This document allows employees to choose between receiving Workers’ Compensation Temporary Total Disability benefits or paid sick and/or annual leave benefits when absent due to a work-related injury.

How to fill out workers compensation temporary total

How to fill out Workers’ Compensation Temporary Total or Sick Leave Benefits Election Form

1. Obtain the Workers’ Compensation Temporary Total or Sick Leave Benefits Election Form from your employer or the appropriate state agency.
2. Read through the entire form to understand the requirements and sections.
3. Fill in your personal information at the top of the form, including your name, address, and employee ID number.
4. Indicate whether you are electing Temporary Total Benefits or Sick Leave Benefits by checking the appropriate box.
5. If electing Temporary Total Benefits, provide the date of the injury, the date you began missing work, and the expected duration of your leave.
6. For Sick Leave Benefits, specify the dates you have used sick leave related to your injury or illness.
7. Complete any additional required sections, such as your supervisor's name and the department you work in.
8. Review your information for accuracy and completeness before signing the form.
9. Submit the completed form to your human resources department or designated personnel as instructed.

Who needs Workers’ Compensation Temporary Total or Sick Leave Benefits Election Form?

1. Employees who have been injured on the job and are unable to work and wish to claim temporary benefits.
2. Workers who have exhausted their sick leave and are applying for additional benefits due to a workplace injury.
3. Employees aware of their rights to worker’s compensation and seeking to formalize their claim for temporary or sick leave benefits.

For pdfFiller’s FAQs

What is Workers’ Compensation Temporary Total or Sick Leave Benefits Election Form?

The Workers’ Compensation Temporary Total or Sick Leave Benefits Election Form is a document used by employees to elect between receiving temporary total benefits from workers' compensation or utilizing sick leave benefits while they are unable to work due to a work-related injury or illness.

Who is required to file Workers’ Compensation Temporary Total or Sick Leave Benefits Election Form?

Employees who have been injured or have become ill as a result of their work-related duties and are seeking either temporary total benefits or sick leave benefits are required to file this form.

How to fill out Workers’ Compensation Temporary Total or Sick Leave Benefits Election Form?

To fill out the form, the employee must provide personal information such as their name, employee ID, and date of injury, select their benefit preference, and sign the form to certify their choice. Additional documentation may be required depending on the employer's policies.

What is the purpose of Workers’ Compensation Temporary Total or Sick Leave Benefits Election Form?

The purpose of the form is to allow employees to formally declare their choice between receiving temporary total benefits from workers' compensation and using their sick leave benefits, ensuring clarity and proper processing of claims.

What information must be reported on Workers’ Compensation Temporary Total or Sick Leave Benefits Election Form?

The form must report the employee's personal details, the nature of the injury or illness, the date of the injury, the choice between benefit options, and any other relevant information as stipulated by the employer or workers' compensation guidelines.