Free Document and Imaging Services 4510-D Pennsylvania Avenue Charleston, WV 25302 Ph... - West Virginia


File Size: 216.9 kB
Pages: 1
Date: October 14, 2008
File Format: PDF
State: West Virginia
Category: Workers Compensation
Author: nfowler
Word Count: 161 Words, 1,037 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.wvinsurance.gov/wc/pdf/notices/microfiche.pdf

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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