Application For Additional Award For Violation Of Specific Safety Requirement {IC-8, 9}

APPLICATION FOR ADDITIONAL AWARD FOR VIOLATION OF SPECIFIC SAFETY REQUIREMENT IN A WORKERS222 COMPENSATION CLAIM IC 8/9 An Equal Opportunity Employer and Service Provider (Rev. 05/19)The applicant hereby makes application for an additional award because of failure of the employer to comply with a specific requirement for the protection of the lives, health, and safety of employees. Claim Number: Address on application is new Injured Worker Information Name Name Address Address City, State, Zip City, State, Zip Employer222s Representative Information Name Name Injured Worker222s Representative Information Telephone Fax Telephone Fax Telephone Fax Telephone Fax Rep ID# Rep ID# Employer Information The Injured Worker was injured on while employed by .The Injury was Fatal Non-Fatal.When the injury occurred, was the Injured Worker employed by a temporary service agency, professional employer organization or staff leasing company? Yes No If 223yes,224 provide the employer information where the work was being performed: Describe, in detail, how the injury occurred (attach extra sheets if necessary): State the specific Ohio Administrative Code Section(s) which were violated, causing the Injured Worker to sustain an injury (attach extra sheets if necessary): Applicant NameDateSignature Provide the information of the persons who witnessed the accident (if available). IMPORTANT: The Safety Violations Investigation Unit may be unable to contact your witnesses if the information is not given. (Employer222s Name) (mm/dd/yyyy) American LegalNet, Inc. www.FormsWorkFlow.com