NOTICE OF CLAIM STATUS Injured Worker: Social Security Number: Workers Address: City, State: ZIP: Date of Injury: Employer: Insurance Company: This is to notify you of the denial or change of status of your workers compensation claim as indicated in the statement checked below: Your claim is denied. Reason: Your benefit payments will be: Reduced Increased Effective Date: Reason: Your benefit payments will be stopped. Effective Date: Reason: Your claim is being investigated. A decision should be made by . Other: Effective Date: Explanation: See attached medical reports. Signature of insurance company adjuster examiner. Name (Typed or Printed): Date: IC Form 8 Notice of Claim Status IDAPA 17.02.08061