Requisition for Workers' Compensation Court of Existing Claims File ­ Exempt Requestor Workers' Compensation Agency File #:____________________________ Date:___________________ In Re Workers' Compensation CEC Claim of: Claimant's Name LAST: _____________________________________________ FIRST: ______________________________________________ G For Review/Copy G To Administration Requisition for Workers' Compensation Court of Existing Claims File ­ Exempt Requestor Workers' Compensation Agency File #:______________________________ Date:_________________ In Re Workers' Compensation CEC Claim of: Claimant's Name LAST: _____________________________________________ FIRST: ______________________________________________ G For Review/Copy G To Administration G To Judge _____________________________ G To Docket Office G To Court Reporter G To Counselor Division G To Health Services Division G To Other ________________________________ G To Judge _____________________________ G To Docket Office G To Court Reporter G To Counselor Division G To Health Services Division G To Other ________________________________ Reason ___________________________________________________________________________ Reason ___________________________________________________________________________ NOTICE: Do Not Remove Files From Building Requestor must review and sign the reverse side of this Requisition Created 1-13-15 Created 1-13-15 NOTICE: Do Not Remove Files From Building Requestor must review and sign the reverse side of this Requisition Requisition for Workers' Compensation Court of Existing Claims File ­ Exempt Requestor Workers' Compensation Agency File #:______________________________ Date:_________________ In Re Workers' Compensation CEC Claim of: Claimant's Name LAST: _____________________________________________ FIRST: ______________________________________________ G For Review/Copy G To Administration Requisition for Workers' Compensation Court of Existing Claims File ­ Exempt Requestor Workers' Compensation Agency File #:______________________________ Date:_________________ In Re Workers' Compensation CEC Claim of: Claimant's Name LAST: _____________________________________________ FIRST: ______________________________________________ G For Review/Copy G To Administration G To Judge _____________________________ G To Docket Office G To Court Reporter G To Counselor Division G To Health Services Division G To Other ________________________________ G To Judge _____________________________ G To Docket Office G To Court Reporter G To Counselor Division G To Health Services Division G To Other ________________________________ Reason ___________________________________________________________________________ Reason ___________________________________________________________________________ NOTICE: Do Not Remove Files From Building Requestor must review and sign the reverse side of this Requisition Created 1-13-15 Created 1-13-15 NOTICE: Do Not Remove Files From Building Requestor must review and sign the reverse side of this Requisition American LegalNet, Inc. www.FormsWorkFlow.com STATEMENT OF EXEMPTION By signing below, the undersigned represents and acknowledges as follows: That the undersigned meets the requirements of an exemption defined by the workers' compensation laws of this state, as indicated below; That the information sought will not be used for any non-exempt purpose. Please circle the number referencing the exemption that applies. 1. Requests made by a public officer/employee in the performance of governmental duties, or as allowed by law; 2. Requests made by an insurer, self-insured employer, third-party claims administrator, or a legal representative thereof, when necessary to process or defend a workers' compensation claim; 3. Requests made by a worker or worker's representative for th worker's claim information; 4. Disclosures made for educational or research purposes, in such a manner that the disclosed information cannot be used to identify any worker who is the subject of a claim; 5. Requests made by a health care or rehabilitation provider, or legal representative thereof, when necessary to process payment for services rendered to a worker. ___________________________________________________________________________________________________________ Signature ____________________________________________________________________________________________________________________________ Printed Name: ____________________________________________________________________________________________________________________________ Street Address City/State/Zip ____________________________________________________________________________________________________________________________ Phone Number STATEMENT OF EXEMPTION By signing below, the undersigned represents and acknowledges as follows: That the undersigned meets the requirements of an exemption defined by the workers' compensation laws of this state, as indicated below; That the information sought will not be used for any non-exempt purpose. Please circle the number referencing the exemption that applies. 1. Requests made by a public officer/employee in the performance of governmental duties, or as allowed by law; 2. Requests made by an insurer, self-insured employer, third-party claims administrator, or a legal representative thereof, when necessary to process or defend a workers' compensation claim; 3. Requests made by a worker or worker's representative for th worker's claim information; 4. Disclosures made for educational or research purposes, in such a manner that the disclosed information cannot be used to identify any worker who is the subject of a claim; 5. Requests made by a health care or rehabilitation provider, or legal representative thereof, when necessary to process payment for services rendered to a worker. ___________________________________________________________________________________________________________ Signature ____________________________________________________________________________________________________________________________ Printed Name: ____________________________________________________________________________________________________________________________ Street Address City/State/Zip ____________________________________________________________________________________________________________________________ Phone Number STATEMENT OF EXEMPTION By signing below, the undersigned represents and acknowled