BWC Subrogation Referral Form | Pdf Fpdf Doc Docx | Ohio

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BWC Subrogation Referral Form | Pdf Fpdf Doc Docx | Ohio

BWC Subrogation Referral Form

This is a Ohio form that can be used for Employers within Workers Comp.

Alternate TextLast updated: 4/13/2015

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Description

BWC Subrogation Referral Form Claimant ________________ Claim No.________________ Claimant's PI Attorney and Address ________________________ ________________________ ________________________ Telephone No.____________ Third Party's Insurance Company Address, Claim No. and Claims Rep ________________________ ________________________ ________________________ Description of Accident ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Refer to: Date of Injury________________ Third Party Name and Address ____________________________ ____________________________ ____________________________ Telephone No.________________ Third Party's Attorney (If known) Name and Address ____________________________ ____________________________ ____________________________ Subrogation Department P.O. Box 15487 Columbus, OH 43215 Phone: (614) 466-6600 Fax: (614) 621-2549 Attached: MVA Report__ Other__ Specify____________ Referred By:__________________ Telephone:___________________ Affiliation:____________________ Date:________________________ American LegalNet, Inc. www.FormsWorkFlow.com

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