Application For Permanent Partial Reconsideration {IC-88}

IC-88 Address on reconsideration is new Application For Permanent Partial Reconsideration CLAIM NUMBER _____________________________________ This form should be delivered to the office where this decision took place. SOCIAL SECURITY #___________________________________ DATE OF INJURY______________________________________ This form is to be used by an injured worker or employer in making application for reconsideration of decisions of District Hearing Officers regarding extent of permanent partial disability as provided in O.R.C. 4123.57 (A). Injured Worker's Address Employer's Address Name Phone Name Phone ( Address ) Address ( ) City, State, Zip Code County City, State, Zip Code County Injured Worker's Representative Name Name Employer's Representative Appealed by Heard at (City)________________________ BWC Administrator Date of Hearing ______________________ Injured Worker Date Order Received __________________ Employer Applicant states that above numbered claim was heard and the following finding made: Applicant requests that such finding be reviewed and reconsidered by the Staff Hearing Officer and that the finding be modified in the following respects: I hereby certify that I have mailed copies of this notice to the injured worker's representative and / or employer's representative (check one or both), on ____________,20____. If there is no representative, I have mailed a copy to the injured worker and /or employer. By checking this box, I certify that I am a non-attorney representative who has been authorized and directed to file this application for reconsideration by the injured Worker Employer (APPELLANT'S SIGNATURE) IC-88 An Equal Opportunity Employer And Service Provider OIC 3004 (Rev. 8/06) American LegalNet, Inc. www.FormsWorkFlow.com Justice For The Workplace