Application For Adjudication Hearing {BWC-3515}

Application for Adjudication Hearing Ohio Administrative Code 4123-14-06 · The employer or the employer's representative uses this form to request a decision by the Adjudicating Committee on the employer's protest that the employer and appropriate BWC business unit has not resolved. · We will consider only billings being protested for collection holds. You must make current premium payments to maintain coverage during your protest. · Mail completed form to: BWC, Legal Division, Adjudication Committee, P Box 15398, Columbus, OH 43215-0398, or send .O. a fax to 614-719-5941. Please call 614-466-6600 with questions. Policy number(s) Tracking number Employer information Name Telephone number ( ) E-mail address Street address City State ZIP code Fax number ( ) Employer representative information Name Telephone number ( ) E-mail address Street address City State ZIP code Fax number ( ) Reason for disagreement with BWC decision on your complaint Attachments/documentation I certify the information provided above is true to the best of my knowledge and belief. Signature and title Date BWC-3515 (7/23/2008) LEGAL-15 American LegalNet, Inc. www.FormsWorkFlow.com