Claim Number: REQUEST FOR .522/.52 RELIEF Injured Worker's Information Employer's Information Name Name Address Address City, State, Zip City, State, Zip Telephone Fax Telephone Fax Injured Worker's Representative's Information Employer's Representative's Information Rep ID# Name Rep ID# Name Telephone Fax Telephone Fax I, the INJURED WORKER INJURED WORKER'S REPRESENTATIVE BWC ADMINISTRATOR, am hereby requesting relief pursuant to: EMPLOYER EMPLOYER'S REPRESENTATIVE ___Ohio Revised Code 4123.522. Relief is requested because I did not receive a copy of the order from the BWC DHO SHO Commission dated I failed to receive the ORDER because the ORDER was: (mm/dd/yyyy) Mailed to an incorrect address; Mailed to the proper address, but I did not receive it (see attached affadavit); Mailed without listing the correct/authorized representative (see attached copy of the previously filed R-1, R-2, or AC-2); Other (please see attached document of explanation). Because I did not receive the ORDER, I was unable to file a timely appeal. Therefore, I request that the ATTACHED appeal or the appeal previously filed on be deemed timely. (mm/dd/yyyy) ___Ohio Revised Code 4123.52. Relief is requested because I did not receive the Notice of the DHO SHO Commission hearing on I failed to receive the NOTICE OF HEARING because the NOTICE was: (mm/dd/yyyy) Mailed to an incorrect address; Mailed to the proper address, but I did not receive it (see attached affadavit); Mailed without listing the correct/authorized representative (see attached copy of the previously filed R-1, R-2, or AC-2); Other (please see attached document of explanation). Because I did not receive the notice, I did not attend the hearing. Therefore, I request that the order from the hearing be VACATED AND A NEW HEARING BE CONDUCTED with proper notice of such to all parties and their representatives. Signature of Applicant Print Applicant's Name STATEMENT OF MUTUAL CONSENT OR OPPOSITION (mm/dd/yyyy) The undersigned party hereby agrees to the Industrial Commission granting relief to the above-signed applicant pursuant to: Ohio Revised Code 4123.522 which will allow the applicant to have the attached appeal construed as timely or will allow the applicant to file an Appeal within 21 days from receipt of compliance letter. Ohio Revised Code 4123.52 which will vacate the order from DHO SHO Commission hearing held on and a new hearing on the contested issued will be rescheduled. (mm/dd/yyyy) I oppose the request and ask for a hearing. Signature of Opposing Party Print Opposing Party's Name An Equal Opportunity Employer and Service Provider Timely, impartial resolution of workers' compensation appeals (mm/dd/yyyy) IC52 OIC 3050 (Rev. 02/12) American LegalNet, Inc. www.FormsWorkFlow.com