Request For File Copies
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Request For File Copies Form. This is a West Virginia form and can be use in Workers Comp.
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Tags: Request For File Copies, BI-910, West Virginia Workers Comp,
BI-910
Return completed form to:
BrickStreet Mutual Insurance
P.O. Box 3151
Charleston, WV 25332
or via fax: 304-941-1294
Request for File Copies
REQUESTER MUST COMPLETE THESE SPACES.
Requester’s Name:
Address:
City, State, Zip:
Telephone Number:
Date of Request:
Injured Worker or Employer Name:
Claim or Policy No.:
Injured Worker’s Date of Injury:
Injured Worker’s Social Security No.:
Injured Worker’s Date of Birth:
Check Type Requested:
CD
Paper
If you are not being provided with appropriate copies, please contact your claims adjuster.
A separate form must be used for EACH file requested.
An authorization (release) must be attached if requester is someone other than the claimant or employer.
Employer
PRINT, SIGN AND DATETHE APPROPRIATE BOX
Print:
Signature:
Date:
Claimant
Print:
Signature:
Date:
Attorney
Print:
Signature:
Date
Other (please specify)
Print:
Signature:
Date:
BrickStreet Mutual Insurance
P.O. Box 3151 Charleston, WV 25332 304-941-1294 (fax)
American LegalNet, Inc.
www.FormsWorkFlow.com
08/10
