Delaware > Workers Compensation
Petition For Review - Delaware
| Petition For Review Form. This is a Delaware form and can be used in Workers Compensation . |
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P E T I T I O N F O R R E V I E W _____________________ TO THE INDUSTRIAL ACCIDENT BOARD OF THE STATE OF DELAWARE SITTING IN AND FOR COUNTY ________________________________ ) __________________ __________ ____________ Employer, ) SS # Carrier File # ) __________________________________________ vs. ) Carrier/Self-Insurer Nam e _______________________________ ) ___________________ __________ ____________ Claima nt. Date of Injury Hearin g No. The undersigned prays that your Honorable Bard shall, after due o notice of the time and place of hearing served on all parties in interest, hear and determine the matter in accordance with the facts and the law, and state iconclusions of fact and rulingts s of law. Petition for Termination of Bnefits, Pursuant to 2347: e _______ Claimant Returned to Work _______ Claimant is Physically Able to Return to Work _______ Missed Employer Medical Examination (s), Pursuant to 2343 (b) _______ Failure to Comply With Bards Order Fo or Voc. Rehab. Services _______ Claimant Partial Disability has Terminated or Diminished _______ Other: ______________________________________________ Petition to Order Vocational Rehabilitation, Pursuant to 2353 (a): _______ To Obtain an Order Requesting the Claimants Cooperation with Vocational Rehabilitation Services Petition for Second Injury Fund, Pursuant to 2327: ________ For Reimbursement from the Second Injury Fund Dated the _______ day of ___________________ A.D. 20_______. _______________________________ Name _______________________________ Address _______________________________ Document No. 60-07-01-90-09-01(04/00)
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