Claim Number: REQUEST FOR CONTINUANCE 1. A Request for Continuance should be submitted to an Industrial Commission office if you want a hearing rescheduled. 2. Documentation in support of the reason for the request must be on file or submitted with the form or the request may be denied. 3. A Request for Continuance based upon good cause is to be made no later than five calendar days prior to the date of hearing. If less than five days prior to the date of hearing, extraordinary circumstances must be shown. 4. The opposing party, must be notified of the request for continuance before it is filed. The results of the contact with the opposing party and/or representative must be set forth below. A failure to follow any of the steps in this procedure may result in the request being denied. Injured Worker'sWorker's Information Injured Representative's Information Name Address City, State, Zip Telephone Fax Name Address City, State, Zip Telephone Fax Employer's Information Injured Worker's Representative's Information Rep ID# Name Telephone Filing Party: Injured Worker Employer BWC Administrator To be heard in (city) Employer's Representative's Information Rep ID# Name Fax Telephone Fax This claim is scheduled for a hearing before a: Injured Worker's Rep Employer's Rep on (mm/dd/yyyy) District Hearing Officer Staff Hearing Officer Commissioners at (time) The continuance is requested because (select one): IC Hearing conflict (no supporting documentation is required). Documented court conflict. Schedule conflict. Specify: Independent medical evaluation has been scheduled on: (mm/dd/yyyy) Recently retained legal counsel and this hinders our ability to obtain evidence necessary for hearing. (representation card attached or already filed on (mm/dd/yyyy)) Please clarify how your request satisfies the due diligence requirements of IC Resolution R12-1-03(D) in the box below: Parties are negotiating a settlement. Injured Worker failed to submit a medical release. Injured Worker failed to attend a scheduled medical evaluation. Parties agree to change the hearing venue to: Parties have requested a pre-hearing conference. Did not receive copy of request for action. Extraordinary or unforeseen circumstances as follows: (city) All parties have agreed to this continuance and waive the time frames as set forth the in section 4123.511 and other applicable provisions of the Ohio Revised Code. Yes No Will you be providing supporting documentation? Yes No, Not Required No, Already on file Opposing party has been notified on (mm/dd/yyyy) by: Telephone Fax Mail Date E-Mail Applicant Name Signature Date Opposing Party Name Signature IC51 An Equal Opportunity Employer and Service Provider Timely, impartial resolution of workers' compensation appeals OIC 1051 Rev. (05/14) American LegalNet, Inc. www.FormsWorkFlow.com