Document and Imaging Services 4510-D Pennsylvania Avenue Charleston, WV 25302 Phone: 304-558-1966 ext. 3016 Fax: 304-558-1021
REQUEST for FILE RECORD COPIES
Requester Information:
Name: Address: City/State/Zip: Phone:
Requested Claimant or Employer Information:
Claimant or Employer Name:
Claim or Risk#: Date of Injury: Date of Birth: SSN or FEIN#:
Check the appropriate box:
Paper Copy (claimant or OIC approved special order)
CD Copy
Please note: This department cannot provide copies of a specific document; therefore, you will receive all legally available documents that the OIC maintains based upon your request. A separate form must be completed for each file requested. Requests should be filled within 10 working days from the date of receipt.
Please provide a brief description for this request:
A release (attorney contract, subpoena, etc.) must be attached if the requester is someone other than the claimant or the employer.
Requester Signature: Relationship to the Claimant or Employer: Date
Revised 10/14/2008