Free WEST VIRGINIA INSURANCE COMMISSION SELF INSURANCE WORKERS' COMPENSATION COMPLAIN... - West Virginia

WEST VIRGINIA INSURANCE COMMISSION SELF INSURANCE WORKERS' COMPENSATION COMPLAINT FORM NAME (person filing complaint):__________________________________________________ (select one) CLAIMANT VENDOR OTHER TELEPHONE:___________________________EMAIL:______________________________ MAILING ADDRESS:___________________________________________________________________

CLAIM NUMBER:_____________________________________________________________ EMPLOYER NAME AND POLICY NUMBER:

VENDOR /TPA NAME AND TELEPHONE NUMBER: ______________________________________________________________________________

SELF INSURED EMPLOYERS ADMINISTER THEIR OWN CLAIMS. HAVE YOU CONTACTED THE EMPLOYER OR TPA? YES NO

You are encouraged to resolve this issue by contacting the employer or the third party administrator prior to filing a formal, written complaint. IS THIS ISSUE CURRENTLY IN THE APPEAL PROCESS? YES NO

HAS THE SUPREME COURT OF APPEALS ISSUED A RULING ON THIS MATTER? YES NO

PLEASE NOTE THAT THE WV INSURANCE COMMISSION CAN NOT INTERVENE IN MATTERS THAT ARE CURRENTLY IN LITIGATION OR OVERTURN RULINGS ISSUED BY ANY LEVEL OF THE APPEAL PROCESS.

PLEASE PROVIDE THE REASON FOR YOUR COMPLAINT (Describe the facts and circumstances which form the basis of your complaint. Provide names and telephone numbers if possible. You may attach additional pages if necessary. Attach copies of any relevant correspondence, or documentation that supports your claim and/or complaint).

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SIGNED:______________________________________________________ DATE:________________

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REVIEWER INFORMATION REVIEWER: ________________________________________ DATE RECEIVED:___________________________________ DATE ISSUE RESOLVED:____________________________

ACTIONS MAILED COMPLAINT FORM : DATE___________________________

TOOK INFORMATION OVER PHONE: DATE_____________________ CALLS MADE (TO/DATE/TIME/RESULTS) __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ BRIEFLY DESCRIBE ACTIONS AND RESOLUTION TO ISSUE __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________