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Employer Adjudication Protest Form. This is a Ohio form and can be use in Employers Workers Comp.
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Tags: Employer Adjudication Protest, BWC-3515, Ohio Workers Comp, Employers
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
Index No.
:
Calendar No.
Employer Adjudication Protest
Better Workers’ Compensation
Built with you in mind.
:
Plaintiff(s)
Ohio Administrative Code
JUDICIAL SUBPOENA4123-14-06
-against:
•This form is to be used by the employer and/or employer’s representative to request a decision by the Adjudicating
Committee on employer’s protest that cannot be resolved between the employer and BWC.
:
•Only billings being protested will be considered for collection holds. Current premium payments will be required to maintain
coverage during your protest.
:
•Mail completed form to: BWC, Legal Operations, Adjudication Committee, P.O. Box 15398, Columbus, OH 43215-0398
OR fax to (614) 719-5941. Please call (614) 466-6600 with questions.
Defendant(s)
:
......................................................
Policy number(s)
Claim number(s)
Employer information THE STATE OF NEW YORK
THE PEOPLE OF
Employer representative information
Name
Name
Telephone number
TO
Fax number
Telephone number
Fax number
(
)
(
(
(
)
)
E-mail address
GREETINGS:
Street address
)
E-mail address
Street address
WE COMMAND YOU, thatcode business and excuses being laid aside, you and each ofZIP code
you attend before
State
State
ZIP all
City
,
the Honorable
at the
Court
located at
County of
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
Date ofin room
action
causing protest
or adjourned date, to testify and give evidence as a witness in this action on the part of the
City
Please indicate specific reason and details for protest
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
result of your failure to comply.
Court in
Witness, Honorable
County,
, one of the Justices of the
day of
, 20
(Attorney must sign above and type name below)
Attorney(s) for
Attachments/documentation
Office and P.O. Address
I certify that the information provided above is true to the best of my knowledge and belief.
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
BWC-3515 (4/18/2002)
LEGAL-15
Signature and tile
Date
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