Free 45442.FH11 - Indiana


File Size: 50.7 kB
Pages: 1
Date: September 21, 2006
File Format: PDF
State: Indiana
Category: Workers Compensation
Author: sbundy
Word Count: 241 Words, 1,643 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.in.gov/icpr/webfile/formsdiv/45442.pdf

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Preview 45442.FH11
REQUEST FOR ASSISTANCE
State Form 45442 (R2 / 5-06)

INSTRUCTIONS:

1. Please print or type 2. Return completed request to the address listed at right. EMPLOYEE INFORMATION
Name of employer Address (number and street) City, state, and ZIP code Telephone number

INDIANA WORKERS COMPENSATION BOARD OMBUDSMAN DIVISION 402 West Washington Street, Room W196 Indianapolis, Indiana 46204 Telephone: (317) 232-3808 Toll free: (800) 824-COMP

EMPLOYER INFORMATION

Name of employee Address (number and street) City, state, and ZIP code Telephone number

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)

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)

Social Security number * Date of birth (month, day, year) Date of accident (month, day, year) Nature of injury: Have you hired an attorney? ** If Yes, name and telephone number of attorney

County of employment

WORKER'S COMPENSATION INSURANCE COMPANY INFORMATION
Name of company Address (number and street) City, state, and ZIP code Telephone number

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)

Contact person(s) Briefly describe your complaint / dispute (attach additional sheets if necessary):

I hereby request the Ombudsman Division of the Worker's Compensation Board to investigate my complaint. I understand that the Ombudsman Division is not a replacement for legal counsel, and that any specific legal questions should be addressed to my attorney.
Signature of employee Date (month, day, year)

* PRIVACY NOTICE: This agency is requesting disclosure of your Social Security number in accordance with IC 22-3-4-13. This disclosure is not mandatory and you will not be penalized for refusing. ** You have no obligation to employ legal counsel under the Indiana Worker's Compensation and Occupational Diseases Acts.