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WA DoL TD-420-062 2017-2026 free printable template

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How to fill out WA DoL TD-420-062

01
Obtain the WA DoL TD-420-062 form from the Washington State Department of Labor and Industries website or at a local office.
02
Read the instructions carefully to understand the requirements for completing the form.
03
Fill out the personal information section, including your name, address, and contact information.
04
Provide details about your work-related injury or illness, including when it occurred and how it happened.
05
Complete the sections regarding medical treatment, including the names of healthcare providers and any treatments received.
06
If applicable, include information about any time missed from work due to the injury or illness.
07
Review your responses for accuracy and completeness before submitting the form.
08
Submit the completed form according to the provided instructions, either online or by mailing it to the appropriate address.

Who needs WA DoL TD-420-062?

01
Employees in Washington State who have suffered a work-related injury or illness.
02
Workers seeking benefits and compensation related to their workplace injury or illness.
03
Individuals who need to report their injury or illness to the Department of Labor and Industries.
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WA DoL TD-420-062 is a form used by the Washington State Department of Labor and Industries for reporting compensation adjustments for workers' compensation insurance.
Employers who provide workers' compensation insurance to their employees in Washington State are required to file WA DoL TD-420-062.
To fill out WA DoL TD-420-062, complete the required fields regarding the employer's information, employee details, compensation adjustments, and any necessary supporting documentation.
The purpose of WA DoL TD-420-062 is to provide the Washington State Department of Labor and Industries with information regarding changes to employees' compensation that may affect workers' compensation premiums.
The information that must be reported on WA DoL TD-420-062 includes employer details, employee names, compensation rates, adjustment amounts, and any relevant notes or explanations.
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