BWC Subrogation Referral Form
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BWC Subrogation Referral Form. This is a Ohio form and can be use in Employers Workers Comp.
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Tags: BWC Subrogation Referral Form, Ohio Workers Comp, Employers
BWC Subrogation Referral Form Claimant ________________ Claim No.________________ Claimant's PI Attorney and Address ________________________ ________________________ ________________________ Telephone No.____________ Third Party's Insurance Company Address, Claim No. and Claims Rep ________________________ ________________________ ________________________ Description of Accident ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Refer to: Date of Injury________________ Third Party Name and Address ____________________________ ____________________________ ____________________________ Telephone No.________________ Third Party's Attorney (If known) Name and Address ____________________________ ____________________________ ____________________________ Subrogation Department P.O. Box 15487 Columbus, OH 43215 Phone: (614) 466-6600 Fax: (614) 621-2549 Attached: MVA Report__ Other__ Specify____________ Referred By:__________________ Telephone:___________________ Affiliation:____________________ Date:________________________ American LegalNet, Inc. www.FormsWorkFlow.com
