Objection to Tentative Order Awarding Permanent Partial Disability Compensation Instructions • Print or type all information. • This form is to be used by the injured worker or employer and/or their authorized representatives to object to the tentative order awarding permanent partial disability compensation. • This objection should be mailed to the address indicated on the Tentative Order. INJURED WORKER INFORMATION Injured worker name Claim number Social Security Number Date of injury NAME AND ADDRESS OF PERSON FILING THE OBJECTION Name Address State City Please indicate your status Injured worker 9-digit ZIP Code Employer Injured worker representative Employer representative INFORMATION FROM TENTATIVE ORDER Date of mailing Entered at Date received ADDITIONAL INFORMATION Check only if: The objecting party intends to file medical evidence. STATEMENT OF OBJECTION I hereby object to the TENTATIVE ORDER for permanent partial disability compensation in the above numbered claim, and request the matter to be set for a hearing before an Industrial Commission hearing officer. I understand that if this OBJECTION is not received by the Bureau of Workers' Compensation within twenty days of the date I received the TENTATIVE ORDER, that order shall become effective and compensation shall be paid as provided in that order. This OBJECTION should be mailed to the P.O. box address indicated on the TENTATIVE ORDER. CERTIFICATE OF SERVICE: I certify that I have served a copy of this objection to tentative order awarding permanent partial disability compensation on all parties and representatives to the claim. Date Signature Distribution: Original – Claim file Copies – as needed Injured worker Injured worker representative Employer Employer representative BWC-1294 (Rev. 9/27/2004) C-167-T American LegalNet, Inc. www.USCourtForms.com