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STATE OF DELAWARE DEPARTMENT OF LABOR DIVISION OF INDUSTRIAL AFFAIRS OFFICE OF WORKERS' COMPENSATION 4425 NORTH MARKET STREET WILMINGTON, DELAWARE 19801 PHONE: (302) 761-8200 FAX: (302) 736-9170 REQUEST FOR COPY OF DOCUMENT NAME OF REQUESTOR: ______________________________ BUSINESS OF REQUESTOR: ADDRESS: DATE:______________ TELEPHONE NUMBER: PARTY REQUESTOR REPRESENTS: _____________________________________________ DOCUMENT(S) BEING REQUESTED & REASON FOR THE REQUEST: ______________________________________________________________________________ ______________________________________________________________________________ CLAIMANT'S NAME: INDUSTRIAL ACCIDENT BOARD (CASE FILE) NUMBER: SOCIAL SECURITY NUMBER: DATE OF ACCIDENT: SIGNATURE OF REQUESTOR: FOR DEPARTMENT OF LABOR USE ONLY NUMBER OF PAGES COPIED MAILING COSTS: $ PICK UP MAIL PAID BY: CHECK @ 0.25 PER PAGE = $ TOTAL AMOUNT DUE $ CASH ACCOUNT _______ PROCESSED BY: ________ DATE PROCESSED: __________ APPROVED BY: ________ American LegalNet, Inc. www.FormsWorkFlow.com