EMPLOYMENT STATUS REPORT, WCB-230
The employer or insurer (which can sometimes be one and the same) may
send the Employment Status Report to the employee for completion of boxes
19 and 20. If the employer/insurer chooses to do this, the report is
due 90 days after the date of injury and every 90 days thereafter. The
employee must receive the request for completion of boxes 19 and 20 at
least 15 days before its due date.
The Employment Status Report is a three-part form that is to be distributed
as follows:
Copy 1 to the Employee.
Copy 2 to the Insurer.
Copy 3 to the Employer.
The Board does not receive a copy of this report.
INSTRUCTIONS FOR COMPLETING EMPLOYMENT
STATUS REPORT, WCB-230
Boxes 1 through 18 are completed by the employer/insurer
Employee
- Insurer File Number
This box is provided for use by the insurer. If the insurer file number
is known at the time of filing the Employment Status Report, enter
it here.
- Employer Name
Enter the employer name as it was entered in box 10 of the Employer's
First Report of Occupational Injury or Disease, WCB‑1.
- Employer
Mailing Address and Phone Number
Enter the address where the employer receives mail. Also enter the
employer's phone number, including area code.
- Insurer Name
Enter the name of the employer's workers' compensation insurer, self‑insured,
or third‑party administrator if there is one.
- Insurer Mailing
Address
Enter the insurer, self‑insured, or third‑party administrator's
mailing address.
- Social Security Number
Enter the employee's social security number.
- WCB File Number
If the preparer knows this number, enter it here.
- Employee Last Name
Enter the employee’s last name as entered in box 27 of the Employer’s
First Report of Occupational Injury or Disease, WCB-1.
- First Name
Enter the employee’s first name as entered in box 28 of the Employer’s
First Report of Occupational Injury of Disease, WCB-1.
- M.I.
Enter the employee’s middle initial as entered in box 29 of the
Employer’s First Report of Occupational Injury or Disease, WCB-1.
- Address – Street
and Number
Enter employee's mailing address.
- City
Enter the city of employee's mailing address.
- State
Enter the state of employee's mailing address.
- Zip
Enter the zip code of employee's mailing address.
- Home Phone Number
Enter the employee's home telephone number, including area code.
- Date
of Injury
Enter the date of the employee’s injury. This date should be
the same as box 42 of the Employer’s First Report of Occupational
Injury or Disease, WCB-1.
- Description of Injury
Enter a complete description of the injury.
- Notice to Employee
Enter the date the completed report is due, the periods covered, and
where to return the completed report (employer or insurer name and
address).
Boxes 19A through 20 are completed by the employee.
19A. Did You Work or Perform Any Services for Pay or Other Benefit During
the Period Stated in the Above Section?
Check either “Yes” or “No.”
19B. If "Yes" is checked, complete this section with the name,
address, and telephone number(s) of each new employer(s). (Use reverse
side of report, if necessary.) Attach verification of income from each
new employer.
19C. What Type(s) of Work Did You Perform in This Employment?
Indicate the type of work done for each new employer.
19D. Dates Employed
Indicate the dates employed with each new employer.
19E. Are You Still Employed?
Check either “Yes” or “No.”
Employee Signature and Date
- Sign and date this form to certify that the information is truthful
and accurate.
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