West Virginia > Workers Comp
Request For Independent Medical Examination BI-RIME - West Virginia
| Request For Independent Medical Examination Form. This is a West Virginia form and can be used in Workers Comp . |
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BI-RIME 01/06 Request for Independent Medical Examination Return completed form to: BrickStreet Mutual Insurance P. O. Box 3151 Charleston, WV 25332-3151 1. Claimant's Name 2. Claim Number 3. Social Security Number 4. Date of Injury 5. Body Part(s) to be examined I, (write your name) _____________________________________________________ request to be sent out for an independent medical examination for an evaluation and determination regarding permanent partial impairment. 6. Mailing Address 7. Phone Number (include area code) Claimant's Signature Date BrickStreet Mutual Insurance P.O. Box 3151 Charleston, WV 25332-3151 American LegalNet, Inc. www.USCourtForms.com
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