Request For Cancellation {IC-50}

Claim Number: REQUEST FOR CANCELLATION 1. A Request for Cancellation should be submitted if you do not need another hearing on a specific issue. If you want to reschedule the hearing at a later date, submit an IC 51, Request for Continuance. 2. Documentation in support of the reason for the request must be submitted or the request may be denied. If documents are already on file, there is no need to resubmit them. 3. The completed form must be filed with an Industrial Commission office. 4. If a Request for Cancellation is filed within two calendar days of the date of hearing, the request may be referred to the hearing officer at the scheduled hearing. 5. The requesting party shall notify all parties of the cancellation request and provide certification of such notification below. A failure to follow any of the steps in this procedure may result in the request being denied. Injured Worker'sWorker's Information Injured Representative's Information Name Address City, State, Zip Telephone Fax Employer's Information Name Address City, State, Zip Telephone Fax Injured Worker's Representative's Information Rep ID# Name Telephone Filing Party: Injured Worker Employer BWC Administrator To be heard in (city) Employer's Representative's Information Rep ID# Name Fax Telephone Fax This claim is scheduled for a hearing before a: Injured Worker's Rep Employer's Rep District Hearing Officer Staff Hearing Officer Commissioners on (mm/dd/yyyy) at (time) The cancellation is requested because (select one): (mm/dd/yyyy) We are withdrawing the motion/C9 filed on (mm/dd/yyyy) We are withdrawing the appeal filed on (mm/dd/yyyy) The self-insured claim has been settled on A settlement application has been filed. The Self-Insuring Employer has fully certified the claim for the following condition(s) The Self-Insuring Employer has fully certified the claim and certification information is attached or has been provided. The Self-Insuring Employer has fully accepted the motion scheduled for a hearing and acceptance information has been provided or will be provided. The claim has been suspended by the IC or BWC. Other Signature Date OIC 1050 IC50 An Equal Opportunity Employer and Service Provider Timely, impartial resolution of workers' compensation appeals (Rev. 02/12) American LegalNet, Inc. www.FormsWorkFlow.com