Request To Correct Employer And Or Policy Number Assignment {BWC-1396}

Request to Correct Employer and/or Policy Number Assignment Instructions Complete this form when alleging BWC or another party incorrectly named you as the employer on a claim or assigned the claim to the incorrect policy number. Please note: You cannot use this form in lieu of an appeal to a decision to allow a claim. Date of injury Claim number Injured worker name Current assigned employer name Current assigned employer policy number Address City Current assigned employer phone number State ZIP code I request: You remove me from the above-named claim; You change the policy number assigned to the claim to another policy number assigned to me. Assign the claim to policy number _________________________. (Please attach proof, e.g., contract of hire, that this is the correct policy number.) Explain why you believe BWC or another party should not assign the claim to your company or the listed policy number. Attach any additional information to support your request. I certify the information provided is correct to the best of my knowledge. I am aware that any person who knowingly makes a false statement, misrepresentation, concealment of fact, or any other act of fraud is subject to felony criminal prosecution and may, under appropriate criminal provisions, be punished by a fine, imprisonment or both. Signature Title Date signed BWC-1396 C-264 American LegalNet, Inc. www.FormsWorkFlow.com