West Virginia > Workers Comp
Request For File Copies BI-910 - West Virginia
| Request For File Copies Form. This is a West Virginia form and can be used in Workers Comp . |
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BI-910 01/06 Request for File Copies Return c ompleted form to: BrickStreet Mutual Insurance P.O. Box 3151 Charleston, WV 25332 Requester's Name : Address: City, State, Zip: R EQ U EST ER MUS T C O MPL E TE T H ESE SP AC ES. Requester Number (if applicable): Telephone Number: Fax: Date of Request: Injured Worker or Employer Name: Claim or Policy No.: Injured Worker's Date of Injury: Injured Worker's Social Security No.: Injured Worker's Date of Birth: CH E CK T HE B O X T H AT AP PL IE S T O R EQ U ES T . Check Type of Media Requested: Fiche Images: Microfiche Copy Paper Electronic Images: CD-R CD-ROM Paper Records Services cannot review injured worker microfiche to pick out specific information or reports. If you are not being provided with appropriate copies, please contact your claims adjuster. A separate form must be used for EACH file requested. An authorization (release) must be attached if requester is someone other than the claimant or employer. Please check box and sign below if you represent the employer: Please check box and sign below if you are the claimant: Signature: _______________________________________________ Signature: _______________________________________________ BrickStreet Mutual Insurance P.O. Box 3151 Charleston, WV 25332 American LegalNet, Inc. www.USCourtForms.com
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