Get Request For Hearing - Contested Claim - Workcompcentral

Filling out the REQUEST FOR HEARING - CONTESTED CLAIM form is an essential step for individuals wishing to appeal an insurer's determination. This guide will provide you with clear instructions on completing the form accurately and efficiently online.

Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to access the document and open it for editing.
2. Fill in the employee information section, including the employee’s name, address, city, state, zip code, telephone number, and claim number.
3. Complete the employer information section with the employer’s name, address, city, state, zip code, and telephone number.
4. Provide details in the third-party administrator (TPA) information section. Enter the TPA’s name, address, city, state, zip code, and telephone number if applicable.
5. Fill in the insurer information section with the insurer's name, address, city, state, zip code, and telephone number.
6. Clearly explain the basis for your appeal in the designated area, ensuring that your argument is succinct and relevant.
7. Indicate if the request for hearing is filed by the injured employee or on behalf of the employer, and ensure the form is dated accordingly.
8. Affix the signature of the injured employee or employer at the appropriate section and include the name of their representative or advisor, if applicable.
9. Review all entries for accuracy, save your changes, and prepare the document for submission.
10. Download, print, or share the completed form as needed for your records or to submit it to the relevant department.

Take the necessary steps to submit your REQUEST FOR HEARING - CONTESTED CLAIM online today.