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Application For Additional Award For Violation Of Specific Safety Requirement In A Workers Compensation Claim IC-8 9 - Ohio
| Application For Additional Award For Violation Of Specific Safety Requirement In A Workers Compensation Claim Form. This is a Ohio form and can be used in Industrial Commission Workers Comp . |
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IC-8/9 The Industrial Commission of Ohio Application for Additional Award for Violation of Specific Safety Requirement in a Workers' Compensation Claim ( For Fatal or Non-Fatal Injuries) CLAIM NUMBER SOCIAL SECURITY # DATE OF INJURY Employer's Address Name Address City, State, Zip Code Mail this form to: Industrial Commission of Ohio VSSR Claims Examiner 30 W. Spring St. 7th floor Columbus, Ohio 43215 Fax: (614) 995-0696 APPLICANT'S ADDRESS IS NEW Applicant's Address Name Address City, State, Zip Code County Phone ( ) County Phone ( ) Applicant's Representative Name Name Employer's Representative The applicant hereby makes application for an additional award because of failure of the employer to comply with a specific requirement for the protection of the lives, health, and safety of employees. 1. The injured worker was injured on _______________________________________at__________________M. (Month) (Day) (Year) 2. While employed by: ________________________________________________________________________ of ______________________________________________________________________________________ (Street Address) (City) (State) (Zip Code) (County) 3. If the injured worker was employed by a temporary service agency, professional employer organization or staff leasing company at the time of the injury, list the name and address of the employer where the work was being performed. ________________________________________________________________________________________ (Name) ________________________________________________________________________________________ (Street Address) (City) (State) (Zip Code) (County) 4. Describe, in detail, how the injury occured (attach extra sheet if necessary). ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ 5. Please state the specific Ohio Administrative Code Section (s) which were violated and which caused the injured worker to sustain an injury:(Attach extra sheet if necessary). ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ 6. IMPORTANT: Please provide the complete names, addresses, and phone numbers (if available) of persons who witnessed the accident. The Safety Violations Investigation Unit may be unable to contact your witnesses if this information is not given. ________________________________________________________________________________________ ________________________________________________________________________________________ (Please attach any additional informaton) (Applicant will sign here) OIC 3018 (Rev 2/05) IC-8 /9 An Equal Opportunity Employer And Service Provider American LegalNet, Inc. www.FormsWorkflow.com
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