Industrial Commission of Ohio REQUEST FOR CONTINUANCE 1. The completed form must be filed with the Industrial CLAIM NUMBER: Commission where the hearing is to be held or with the Regional Hearing Administrator of the Industrial Commission. Facsimile transmission is acceptable. 2. 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 that could not be foreseen must be shown. 3. If a continuance is granted, it is the responsibility of the parties to contact their respective clients. 4. The opposing party's representative, or, if not represented, then 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 should be set forth below (e.g., agreed, did not agree, left message, etc.). A failure to follow this notification procedure may result in the request being denied. 5. A request for continuance must be copied to the opposing party and representative via facsimile or mail. 6. Documentation in support of the reason for request must be submitted or the request will be denied. Claimant Employer Name Name Address Address County City, State, Zip Code Phone ( County City, State, Zip Code Phone ( ) ) Employer Representative's ID Claimant Representative's ID Name Name Address Address City, State, Zip Code City, State, Zip Code Phone ( ) Fax ( Phone ( ) ) Fax ( ) I the emploryer ___, claimant ___, Administrator ___, request a continuance in the above numbered claim. This claim is scheduled for hearing before a DHO ,SHO , Commissioners ___ in (city) ______________________ on (date) ___________, 20___, at _____a.m., _____ p.m., in room number _____. jkjkjkjjkjkjjk Reason for Request Supporting documentation attached: This request was copied to at ( ) via facsimile mail or SIGNING PARTIES AGREE TO THIS CONTINUANCE AND TO WAIVE THE TIME FRAMES AS SET FORTH IN SECTION 4123.511 AND OTHER APPLICABLE PROVISIONS OF THE OHIO REVISED CODE. REPRESENTATIVES CERTIFY THAT THEIR RESPECTIVE CLIENTS HAVE BEEN INFORMED OF THE TIME FRAMES AND HAVE AGREED TO WAIVE SAME. Telephone ( Date Fax ( ) Telephone ( (Applicant Name) ) ) Fax ( ) (Signature) (Opposing Party Name) Date Telephone Authorization (Signature) TO BE COMPLETED BY THE INDUSTRIAL COMMISSION Granted Hearing Administrator OIC1004 (02/03) Denied Date Stamp Here Reason Prompt Code ___________________ IC 51 American LegalNet, Inc. www.USCourtForms.com