Request To Protest Decision
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Request To Protest Decision Form. This is a West Virginia form and can be use in Workers Comp.
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Tags: Request To Protest Decision, IC-RPD, West Virginia Workers Comp,
IC-RPD
02/06
Request to
Protest Decision
West Virginia
Insurance Commission
1. Protest being requested by:
Claimant
Return completed form to:
Office of Judges
P. O. Box 2233
Charleston, WV 25328-2233
Employer
2. Protesting Person’s Name
3. Protesting Person’s Mailing Address
4. Protesting Person’s Phone Number (include area code)
5. Claimant’s Name (if different from protestor)
6. Claim Number
7. Social Security Number
8. Date of Injury
9. I protest the decision from BrickStreet Insurance dated: ___________ / ___________ / _____________
Office of Judges
P.O. Box 2233
Charleston, WV
25328-2233
You must send this request to protest, along with a copy of the order, to:
Office of Judges, P.O. Box 2233, Charleston, West Virginia 25328-2233.
Copies also must be sent to all other parties to the claim and to:
BrickStreet Mutual Insurance, P.O. Box 3151, Charleston, West Virginia 25332-3151.
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