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DC PSWCP Form 9-A 2016 free printable template

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TURN OVER FOR MORE INSTRUCTIONS 441 Fourth Street NW Suite 800 South Washington DC 20001 Tel 202 727-8600 http //orm.dc.gov/ PSWCP Form 9-A Adopted 12/2016 District of Columbia Government Page 1 of 2 Reason for Disagreement with Program Decision You MUST answer all of the following questions. 03 e Appeal of permanent disability determination made pursuant to D.C. Code 1-623. 07 a Appeal of suspension forfeiture or termination of awarded benefits for Failure to report earnings...
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DC PSWCP Form 9-A Form Versions

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How to fill out DC PSWCP Form 9-A

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How to fill out DC PSWCP Form 9-A

01
Obtain the DC PSWCP Form 9-A from the appropriate authority or website.
02
Read the instructions carefully before filling out the form.
03
Fill in your name in the designated 'Applicant Name' section.
04
Provide your contact information including phone number and email address.
05
Indicate your status as a worker (e.g., employee, contractor) in the specified section.
06
Complete the sections regarding your work history, including dates of employment and job descriptions.
07
If applicable, provide information about any prior claims or benefits you've received.
08
Sign and date the form to certify that all information is accurate.
09
Submit the completed form to the correct office as directed by the instructions.

Who needs DC PSWCP Form 9-A?

01
Individuals who have been injured or become ill as a result of their work-related duties.
02
Employees seeking benefits under the DC Public Sector Workers' Compensation Program.
03
Contractors or subcontractors working in the public sector who require compensation coverage.
04
Representatives or advocates assisting injured workers in filing their claims.
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DC PSWCP Form 9-A is a specific form required for reporting workers' compensation claims in Washington, D.C.
Employers in Washington, D.C. who have workers' compensation claims must file DC PSWCP Form 9-A.
To fill out DC PSWCP Form 9-A, you need to provide the necessary claim details such as the injured worker's information, the nature of the injury, and any relevant employer information as required by the form's instructions.
The purpose of DC PSWCP Form 9-A is to provide a standardized method for employers to report workers' compensation injury claims to the Department of Employment Services in D.C.
The information that must be reported on DC PSWCP Form 9-A includes the employee's name, date of injury, details of the incident, employer information, and any medical treatment information related to the claim.
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