Notice Of Inability To Determine Liability Or Request For Additional Time {48557}

NOTICE OF INABILITY TO DETERMINE LIABILITY/ REQUEST FOR ADDITIONAL TIME State Form 48557 (R2 / 7-12) PRIVACY NOTICE * This agency is requesting disclosure of your Social Security number in accordance with IC 22-3-4-13. This disclosure is not mandatory and you will not be penalized for refusing. Accident number INSTRUCTIONS: 1. Please type or print in ink. 2. Complete appropriate sections of this document and sign in the space below. CLAIM INFORMATION Name of employer Address of employer (number and street, city, state, and ZIP code) Name of insurer / TPA Name of adjuster E-mail address of adjuster Name of employee Address of employee (number and street, city, state, and ZIP code) Federal Identification number Telephone number ( ) Insurer claim number Date of injury (month, day, year) Date employer notified of injury (month, day, year) Date employer notified of work restriction or prohibition (month, day, year) Telephone number of adjuster ( ) Social Security number * Telephone number ( ) REQUEST FOR ADDITIONAL TIME Notice of inability to determine liability must be made in writing and received by the Board and the employee not later than thirty (30) days after the employer's knowledge of the injury (IC 22-3-3-7). (Check appropriate action below.) Medical care only claim from Nature of alleged injury: to . Initial request for additional sixty (60) days. Reasons determination cannot be made within thirty (30) days: Facts or circumstances necessary to determine liability: Request for additional time beyond sixty (60) days. (Must include details of first request above.) Extraordinary circumstances which have precluded determination of liability: Status of investigation: Facts or circumstances necessary to determine liability: Timetable for completion of remaining investigation: EMPLOYER / CARRIER CERTIFICATION Employer / Adjuster must sign below to certify service. Signature of employer / adjuster Date issued (month, day, year) FOR BOARD USE ONLY WORKERS COMPENSATION BOARD 402 W. Washington St., Rm. W196 Indianapolis, IN 46204-2753 By: U.S. Mail Personal Service American LegalNet, Inc. www.FormsWorkFlow.com