Ohio > Workers Comp > Employers
Employer Adjudication Protest BWC-3515 - Ohio
| Employer Adjudication Protest Form. This is a Ohio form and can be used in Employers Workers Comp . |
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COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Better Workers' Compensation Index No. : Calendar No. Employer Adjudication Protest Plaintiff(s) : Ohio Administrative Code JUDICIAL SUBPOENA4123-14-06 Built with you in mind. -against: ·This form is to be used by the employer and/or employer's representative to request a decision by the Adjudicating Committee on employer's protest that cannot be resolved between the employer and BWC. ·Only billings being protested will be considered for collection holds. Current premium payments will be required to maintain coverage during your protest. ·Mail completed form to: BWC, Legal Operations, Adjudication Committee, P.O. Box 15398, Columbus, OH 43215-0398 OR fax to (614) 719-5941. Please call (614) 466-6600 with questions. Policy number(s) : : Defendant(s) : ...................................................... Claim number(s) Name Employer information THE STATE OF NEW YORK THE PEOPLE OF Telephone number ( ) Employer representative information Name Telephone number ( ) E-mail address Street address Fax number ( ) TO Fax number ( ) E-mail address GREETINGS: Street address City WE COMMAND YOU, thatcode business and excuses being laid aside, you and each ofZIP code you attend before State State ZIP all City , the Honorable at the Court located at County of , on the day of , 20 , at o'clock in the noon, and at any recessed Date ofin room action causing protest or adjourned date, to testify and give evidence as a witness in this action on the part of the Please indicate specific reason and details for protest Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Witness, Honorable County, , one of the Justices of the day of , 20 Court in (Attorney must sign above and type name below) Attorney(s) for Attachments/documentation Office and P.O. Address I certify that the information provided above is true to the best of my knowledge and belief. Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: BWC-3515 (4/18/2002) LEGAL-15 Signature and tile Date American LegalNet, Inc. www.USCourtForms.com
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