Employers looking for submit for multiple employees may complete the information below and submit a completed PDF form for review.
Each PDF form allows for submissions of up to 10 employees. If you have more than 10 employees, please complete a new submission until you have submitted for all employees for which you are seeking charge relief.
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I attest, under penalty of perjury, that all information provided on this form is true and accurate. Further, I understand that intentional misrepresentation of information is fraud and may subject me to administrative penalties.
