NOTICE OF CLAIM STATUS
Injured Worker: Worker's Address: Date of Injury: Employer: Insurance Company: City, State: Social Security Number: ZIP:
This is to notify you of the denial or change of status of your workers' compensation claim as indicated in the statement checked below: Your claim is denied. Reason: Your benefit payments will be: Reduced Increased Effective Date: Reason:
Your benefit payments will be stopped. Effective Date: Reason: .
Your claim is being investigated. A decision should be made by Other: Explanation: See attached medical reports. Effective Date:
Signature of insurance company adjuster examiner. Name (Typed or Printed): Date:
IC Form 8 Notice of Claim Status