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Begin by entering the WCB Case Number and Carrier Case Number in the designated fields. This information is crucial for tracking your request.
Fill in the Carrier Code and Date of Injury, ensuring that you use the correct format (mm/dd/yy) for clarity.
Provide the District Office address where notices should be sent. If there’s a new address, check the corresponding box.
Complete sections for Claimant, Employer, and Carrier details. Make sure to include any Attorney or Representative ID numbers if applicable.
In the instructions section, check all reasons that apply for Board action regarding the claim. Attach any required documentation as specified.
Finally, certify your request by checking the appropriate box regarding discussions with opposing parties and provide your contact information before submitting.
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