BEFORE THE WORKERS' COMPENSATION BOARD STATE OF OREGON In the Matter of the Compensation ) ) of ) ) ) ______________________, Claimant ) WCB Case No. ________________ Claim No. ____________________ DOI: ________________________ WCD File No. _________________ REQUEST FOR BOARD REVIEW
____________________ requests Board review of ALJ _______________'s order dated _______________. Review is requested because _________________ __________________________________________________________________.
Payment of compensation awarded by the ALJ's order be stayed under ORS 656.313.
will /
will not
Dated this _____ day of ________________, 200___.
______________________________ Attorney for ____________________
[Also attach certificate of service by mail, fax, or e-mail.]
(4/06 WCB)