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Tative Information Employer s Representative Information Rep ID# Rep ID# Name Name Telephone Fax Telephone Injured Worker Employer BWC Administrator Heard on Fax Appealing Order of: Appealed by: Hearing Location Fax BWC Administrator District Hearing Officer Staff Hearing Officer (city) (mm/dd/yyyy) Date Order Received (mm/dd/yyyy) NOTE: If you are filing an appeal of a staff hearing officer order, failure to identify the necessary documents may result in a determination no.
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