Delaware > Workers Compensation
Petition To Determine Disfigurement - Delaware
| Petition To Determine Disfigurement Form. This is a Delaware form and can be used in Workers Compensation . |
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PETITION TO DETERMINE DISFIGUREMENT __________________ To The Industrial Accident Board of the State of Delaware Sitting in and for County ______________________ Petitioner ) ) vs. ) ______________________________ ) ) _____________________ Defendant ) The undersigned petitioner respectfully represents: Being desirous of having a hearing on the ground that _________________________ has sustained a disfigurement to the following part/parts of his body __________________________ resulting from a compensable industrial accident which occurred on_______________________ and became permanent as of ______________________ , the undersigned respectfully prays that your Honorable Board shall, after due 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 its conclusion of fact and rulings of law. Dated this _____________________ day of ______________________ A.D. 20_____________ _____________________________ Name _____________________________ Address _____________________________ Document Control No.: 60-07-002-85-11-05
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