Request For Assistance {45442}

REQUEST FOR ASSISTANCE State Form 45442 (R2 / 5-06) INSTRUCTIONS: 1. Please print or type 2. Return completed request to the address listed at right. EMPLOYEE INFORMATION Name of employer Address (number and street) City, state, and ZIP code Telephone number INDIANA WORKERS COMPENSATION BOARD OMBUDSMAN DIVISION 402 West Washington Street, Room W196 Indianapolis, Indiana 46204 Telephone: (317) 232-3808 Toll free: (800) 824-COMP EMPLOYER INFORMATION Name of employee Address (number and street) City, state, and ZIP code Telephone number ( ) ( ) Social Security number * Date of birth (month, day, year) Date of accident (month, day, year) Nature of injury: Have you hired an attorney? ** If Yes, name and telephone number of attorney County of employment WORKER'S COMPENSATION INSURANCE COMPANY INFORMATION Name of company Address (number and street) City, state, and ZIP code Telephone number ( ) Contact person(s) Briefly describe your complaint / dispute (attach additional sheets if necessary): I hereby request the Ombudsman Division of the Worker's Compensation Board to investigate my complaint. I understand that the Ombudsman Division is not a replacement for legal counsel, and that any specific legal questions should be addressed to my attorney. Signature of employee Date (month, day, year) * 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. ** You have no obligation to employ legal counsel under the Indiana Worker's Compensation and Occupational Diseases Acts. American LegalNet, Inc. www.FormsWorkflow.com