Form Lwc 65W PDF Details

Are you a contractor working in the construction industry? If so, you may be interested in learning about a new form that has been released by the California Workers' Compensation Appeals Board. The form, known as Lwc 65W, is designed to help contractors better manage their workers' compensation claims. In this blog post, we will provide an overview of the form and explain how it can benefit your business. Stay tuned for future blog posts that will provide more detailed information on Lwc 65W. Thanks for reading!

QuestionAnswer
Form NameForm Lwc 65W
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesbat adjusdication lwc, bat adjustments lwc la gov, bat adjudication lwc la gov email, bat adjudications lwc la gov

Form Preview Example

LWC 65W (07/09)

ELIGIBILITY REVIEW

___________________________________

________________________

Print Your Name

Your Social Security Number

To maintain your eligibility requirements for unemployment insurance benefits, a review of your work search record is required. When instructed, you must complete the items below and fax this form to (225) 346-6068 or mail this form to the Louisiana Workforce Commission, Adjudication Support Unit, P. O. Box 91253, Baton Rouge, LA 70821-1253. This form is semi-interactive and may be filled out online, then printed and mailed. Failure to return this form timely could result

in your being disqualified for benefits.

Answer the following questions:

 

 

 

 

 

 

 

 

 

 

 

 

1.

 

Are you attending any school or training program now? If so, list the name

 

 

 

Yes

 

No

 

 

of the school and the course of study:

 

 

 

 

___________________________________________________________

 

 

 

 

 

 

 

2.

 

Is there any reason why you cannot look for a job or accept one now?

 

 

 

Yes

 

No

 

 

(Such as a lack of transportation, a physical disability, pregnancy, childcare

 

 

 

 

 

problems, etc.)

 

 

 

 

 

 

 

 

3.

 

Are you working full-time, part-time, in self-employment, on a

 

 

 

Yes

 

No

 

 

commission basis, in operating a farm or as an elected official, etc?

 

 

 

 

 

4.

 

Do you have a definite prospect of employment? (In other words, have

 

 

Yes

 

No

 

 

you been given a date to begin work by a specific employer?) If so, list the

 

 

 

 

 

 

 

 

 

 

name of the employer and the date you will begin working.

 

 

 

 

____________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Record of work search or union contacts:

 

 

 

List one job contact you have made in each of the last three (3) weeks:

 

 

 

 

Date

 

Name of Company or Name of Union Officer Contacted

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Certification: I have answered these questions and provided a record of my work search contacts to obtain unemployment benefits. I know that this information is subject to verification and that the law provides penalties for false statements.

Your Signature:Today’s Date:

Please Print Your Mailing Address:

_____________________________________________

Your City, State and Zip Code:

_____________________________________________

Your Telephone Number:

_____________________________________________

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