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Request For Claim Information F101-010-111 - Washington

Request For Claim Information Form. This is a Washington form and can be used in Claims Workers Comp .
 Fillable pdf Last Modified 1/30/2004
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Department of Labor and Industries PO Box 44291 Olympia WA 98504-4291 Department of Labor and Industries Self-Insurance PO Box 44892 Olympia WA 98504-4892 For the worker or worker's representative Or the employer or the employer's representative Request for Claim Information This form must be completed in full. Copies of documents are a chargeable item. Claim Number Worker's Name Name of Person Making Request Address City State I am: Worker Zip Code Other I am requesting my claim file. I am requesting the following information from my claim file (for example, "the panel exam of February 4, 2013" etc. please let below): I am the worker's authorized representative requesting the claim file for the worker named above. I understand that the file contains confidential information and by accepting the file, I accept full responsibility for any use made of this information. My authorization is: On file Attached I am the employer or employer's representative requesting the claim file for the worker name above. I understand that the file contains confidential information and by accepting the file, I accept full responsibility for any use made of this information. Signature Date For Department Use Only: Action taken on request: Name of person taking action: Date action taken: Section/Office F101-010-111 Request for Claim Information 02-2014 American LegalNet, Inc. www.FormsWorkFlow.com
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