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Memo Of Denial Of Workers Compensation Benefits 9 WCA-1 - New Hampshire

Memo Of Denial Of Workers Compensation Benefits Form. This is a New Hampshire form and can be used in General Workers Comp .
 Fillable pdf Last Modified 4/11/2005
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LAB 500 Memo of Denial of Workers' Compensation Benefits Claimant's Name Employer Date of Accident Social Security No. Identification No. Date First Report Received YOUR CLAIM TO WORKERS' COMPENSATION BENEFITS IS HEREBY DENIED BY EMPLOYER OR CARRIER FOR REASONS INDICATED BELOW. IF YOU SO ELECT, YOU MAY PETITION THE COMMISSIONER OF LABOR, 95 PLEASANT ST., CONCORD NEW HAMPSHIRE, 03301, IN WRITING FOR A HEARING. YOU MUST REQUEST A HEARING WITHIN 18 MONTHS OF THE DENIAL REASONS 1. u 2. u 3. u 4. u Explanation No Employer-Employee Relationship (par. VI, VII, VIII, IX, RSA 281-A:2) No Causal Relationship to Employment (pars. XI, XIII, RSA 281-A:2) Employee's Fault ( RSA 281-A:14) Improper Notice of Injury by Employee (RSA 281-A:19, 20, 21) Authorized Representative Insurance Carrier and Number Carrier's Address Phone # Date THIS FORM IS NOT TO BE USED TO DENY MEDICAL BILLS ON AN ACCEPTED CLAIM 9 WCA-1 (9/2015) American LegalNet, Inc. www.FormsWorkFlow.com Email Address
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