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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

IDAPA 17.02.08061