Document Number: WKC-6119
Description: This form is completed from the Social Security Administration Office information. It shows how Worker's Compensation arrived with the Social Security Offset. It is used internally by Worker's Compensation staff, and also by insurance companies and attorneys. Most of the time this form is sent to the insurance company from the Department of Workforce Development.
Comments: This form is not fill-enabled. It can be printed and completed by hand.
Content Contact: Lynn Weinberger
Document Attachment: WKC-6119 (pdf/125 KB)
Note: If you need this form in an alternate format, please send a message to the Content Contact listed above.