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Injured Worker Authorized Representative BWC-6102 - Ohio

Injured Worker Authorized Representative Form. This is a Ohio form and can be used in Injured Workers Workers Comp .
 Fillable pdf Last Modified 3/3/2009
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InjuredWorkerBetterWorkersCompensation Builtwith youinmind. AuthorizedRepresentative INSTRUCTIONS: ThisformmustbecompletedinitsentiretybytheInjuredWorkerandRepresentativeand?ledwiththeOhio BureauofWorkersCompensation(BWC). AvalidBWCRepresentativeI.D.numberisrequired. Toobtain avalid Representative I.D. number contactthe Central Of?ce, Customer Assistance Desk at 614.466.1958or614.466.1563orinquireatanyBWCCustomerServiceOf?ceInformationdesk. Injuredworkername Claimnumber Injuredworkeraddress City,State,ZIPCode Dateofinjury Phonenumber SocialSecurityNumber Employernameatdateofinjury REPRESENTATIVE Representativename RepresentativeI.D.number Address FederaltaxnumberorSocialSecurityNumber City,State,ZIPCode Telephonenumber Faxnumber AUTHORIZATION IherebyauthorizetheaboverepresentativetorepresentmeintheaboveclaimbeforetheOhioBureauofWorkersCompensationandthe IndustrialCommissionofOhio.ThisauthorizationalsoentitlesthisRepresentativetoautomaticallyreceivecorrespondencegeneratedin theaboveclaim?le. X Signatureofinjuredworker DateofAuthorization BWC-6102(6/15/2004) R-2 American LegalNet, Inc. www.USCourtForms.com
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