Employee Waiver of Workers Compensation Form
Employee Waiver of Workers Compensation Form
Please provide all the necessary information below to complete this form.
Name
Employee ID
Position/Title
Department
Acknowledgment
I, the understand and acknowledge that I am voluntarily waiving my rights to workers' compensation benefits provided by [Your Company Name]. I am aware that workers' compensation typically covers expenses related to work-related injuries or illnesses, including medical treatment and lost wages. By signing this form, I am choosing to forfeit these benefits.
Date:
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