Free 48557.PDF - Indiana

Accident Number

NOTICE OF INABILITY TO DETERMINE LIABILITY/ REQUEST FOR ADDITIONAL TIME STATE FORM 48557 (9-97)
INSTRUCTIONS: Complete appropriate sections of this document and sign in the space below. PLEASE TYPE OR PRINT IN INK.

PRIVACY NOTICE
*This agency is requesting disclosure of your Social Security number in accordance with IC 223-4-13. This disclosure is not mandatory and you will not be penalized for refusing.

CLAIM INFORMATION
Name of Employer Name of Insurer Address (city, state, zip) Name of Employee *Social Security Number Federal ID Number Address of Employer Insurer Claim Number Telephone Number Address of Employee Telephone Number ( ) Telephone Number ( ) Date of Injury

REQUEST FOR ADDITIONAL TIME Notice of inability to determine liability must be made in writing and mailed to The Board and the employee not later than thirty (30) days after the employer's knowledge of the injury (IC-22-3-3-7). (Check appropriate action below.) p Request for additional thirty (30) days. Reasons determination cannot be made within thirty (30) days:

_________________________________________________

_________________________________________________________________________________________________________ Facts or circumstances necessary to determine liability: _________________________________________________________ _________________________________________________________________________________________________________ p Request for additional time beyond thirty (30) days Extraordinary circumstances which have precluded determination of liability: ______________________________________ __________________________________________________________________________________________________________ Status of the investigation: __________________________________________________________________________________ __________________________________________________________________________________________________________ Facts or circumstances necessary to determine liability: _________________________________________________________ __________________________________________________________________________________________________________ Timetable for completion of remaining investigation: ____________________________________________________________ __________________________________________________________________________________________________________

EMPLOYER/CARRIER CERTIFICATION Employer must sign below to certify service. Signature of employer/carrier Workers Compensation Board 402 W. Washington, Rm W196 Indianapolis, IN 46204-2753

FOR BOARD USE ONLY

Date signed (month, day, year)

By : p U.S. Mail p Personal Service