Objection To Tentative Order {OIC 3051}

Objection to Tentative Order Determining the Percentage of Permanent Partial Disability Compensation Instructions * Print or type all information. * This form is to be used by the injured worker and employer and/or their authorized representatives to object to the tentative order determining a percentage of permanant partial disability compensation. * This objection should be sent to the local Industrial Commission office. INJURED WORKER INFORMATION Injured worker name Social Security Number Date of injury Claim number NAME AND ADDRESS OF PERSON FILING OBJECTION Name Address City Please indicate your status Injured worker Injured worker representative Employer Employer representative State 9-digit ZIP Code INFORMATION FROM TENTATIVE ORDER Date of order Date received ADDITIONAL INFORMATION Choose one: I intend to file additional medical evidence. I do not intend to file additional medical evidence. STATEMENT OF OBJECTION I hereby OBJECT to the TENTATIVE ORDER that determined the percentage of permanent partial disability compensation in the above numbered claim, and request the matter to be set for a hearing before an Industrial Commission district hearing officer. I understand that if this OBJECTION is not received within twenty days of the date I received the TENTATIVE ORDER, that order shall become effective and compensation shall be paid as provided in that order. CERTIFICATE OF SERVICE: I certify that I have served a copy of this objection to the tentative order determining a percentage of permanent partial disability compensation to the injured worker's representative and / or employer's representative (check one or both), on ________________, 20____. If there is no representative, I have mailed a copy to the injured worker and / or employer. By checking this box, I certify that I am a non-attorney representative who has been authorized and directed to file this objection by the injured worker employer. Signature Date IC-167-T OIC 3051 (rev. 11/07) An Equal Opportunity Employer And Service Provider American LegalNet, Inc. www.FormsWorkFlow.com