Application For Additional Award For Violation Of Specific Safety Requirement In A Workers Compensation Claim
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Application For Additional Award For Violation Of Specific Safety Requirement In A Workers Compensation Claim Form. This is a Ohio form and can be use in Industrial Commission Workers Comp.
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Tags: Application For Additional Award For Violation Of Specific Safety Requirement In A Workers Compensation Claim, IC-8 9, Ohio Workers Comp, Industrial Commission
Application for Additional Award for
Violation of Specific Safety Requirement in a
Workers' Compensation Claim
( For Fatal or
Non-Fatal Injuries)
The Industrial
Commission
of Ohio
IC-8/9
Mail this form to:
Industrial Commission of Ohio
VSSR Claims Examiner
30 W. Spring St. 7th floor
Columbus, Ohio 43215
Fax: (614) 995-0696
CLAIM NUMBER
SOCIAL SECURITY #
DATE OF INJURY
APPLICANT'S ADDRESS IS NEW
Employer's Address
Applicant's Address
Name
Name
Address
Address
City, State, Zip Code
City, State, Zip Code
County
Phone
(
)
Phone
(
)
County
Applicant's Representative
Employer's Representative
Name
Name
The applicant hereby makes application for an additional award because of failure of the employer
to comply with a specific requirement for the protection of the lives, health, and safety of employees.
1.
The injured worker was injured on _______________________________________at__________________M.
(Month)
2.
(Day)
(Year)
While employed by: ________________________________________________________________________
of ______________________________________________________________________________________
(Street Address)
3.
(City)
(State)
(Zip Code)
(County)
If the injured worker was employed by a temporary service agency, professional employer organization
or staff leasing company at the time of the injury, list the name and address of the employer where the
work was being performed.
________________________________________________________________________________________
(Name)
________________________________________________________________________________________
(Street Address)
4.
(City)
(State)
(Zip Code)
(County)
Describe, in detail, how the injury occured (attach extra sheet if necessary).
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
5.
Please state the specific Ohio Administrative Code Section (s) which were violated and which caused the
injured worker to sustain an injury:(Attach extra sheet if necessary).
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
6.
IMPORTANT: Please provide the complete names, addresses, and phone numbers (if available) of persons
who witnessed the accident. The Safety Violations Investigation Unit may be unable to contact your
witnesses if this information is not given.
________________________________________________________________________________________
________________________________________________________________________________________
(Please attach any additional informaton)
(Applicant will sign here)
IC-8 /9
OIC 3018 (Rev 2/05)
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