Free Request for Board Review Form pdf format - Oregon


File Size: 10.2 kB
Pages: 1
File Format: PDF
State: Oregon
Category: Workers Compensation
Author: sticeml
Word Count: 77 Words, 788 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.cbs.state.or.us/external/wcb/pdf_file/forms/reqbdreview.pdf

Download Request for Board Review Form pdf format ( 10.2 kB)


Preview Request for Board Review Form pdf format
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)