Claim Number: REQUEST FOR CORRECTED ORDER This form is to be used to request a correction of a clerical or typographical error contained in an Industrial Commission order. Injured Worker's Worker Information Injured Representative's Information Name Address City, State, Zip Telephone Fax Name Address City, State, Zip Telephone Fax Employer's Representative Information Rep ID# Name Fax Telephone Fax Employer Information Injured Worker's Representative Information Rep ID# Name Telephone Correction Requested by: Injured Worker Employer BWC Administrator Staff Hearing Officer Commissioners Request correction for a hearing held before: Hearing Location Heard by District Hearing Officer Heard on (city) (mm/dd/yyyy) Date Order Received (mm/dd/yyyy) Please attach a copy of the order you wish to have corrected. IDENTIFY ERROR: Have you filed an appeal? Yes No Agree If yes, then upon issuance of a corrected order, I hereby agree to dismiss said appeal. This does not affect your right to file an appeal to the corrected order. If no, and the Industrial Commission determines not to issue a corrected order, this Request for Corrected Order will be construed as an appeal. I hereby certify that I am authorized to represent the and have notified all parties of this request. Signature of Requesting Party Injured Worker, Employer, BWC Telephone of Requesting Party Yes No All parties, including BWC in State Fund claims, have agreed to this corrected order request. Opposing parties were notified on (mm/dd/yyyy) FOR INDUSTRIAL COMMISSION OF OHIO USE ONLY Request for correction is: Granted Denied Appeal Dismissed Explain Date (mm/dd/yyyy) Hearing Officer Filing Party notified on Date (mm/dd/yyyy) By An Equal Opportunity Employer and Service Provider Timely, impartial resolution of workers' compensation appeals IC 13 OIC 1013 American LegalNet, Inc. www.FormsWorkFlow.com (Rev. 04/15)