1. A. To file a claim, file with the Commission’s Claims Department a Form 50, Form 52, or a letter as provided below.

2. B. To file a claim on a Form 50 or Form 52, mark the box at the signature line which states “I am filing a claim. I am not requesting a hearing at this time.”

   1. (1) Address and deliver the form to the Claims Department.
   2. (2) Filing a claim requires the WCC file number or the Coverage Coding Form 39 must be included. This requirement may be waived for unrepresented claimants.
   3. (3) Filing a claim does not request a hearing nor is the employer’s representative required to file a Form 51 or 53.

3. C. A letter filed with the Commission also files a claim. The letter should include the information listed in items (1) through (13) below:

   1. (1) Claimant’s name (and worker’s name, if different);
   2. (2) Claimant’s address (and worker’s address, if different);
   3. (3) Claimant’s home and work telephone numbers (and worker’s home and work telephone numbers, if different);
   4. (4) Claimant’s social security number (and worker’s social security number, if different);
   5. (5) Employer’s name;
   6. (6) Employer’s address;
   7. (7) Employer’s telephone number;
   8. (8) Employer’s insurance carrier, if known;
   9. (9) Date of injury;
   10. (10) The county in which the injury occurred;
   11. (11) Type of injury (to which area of body);
   12. (12) Description of the accident;
   13. (13) The WCC file number or Coverage Coding Form must be included.
4. D. Failure to include any of the information above does not bar the claim if the information necessary to an issue in the claim is given to the Commission upon request.
5. E. The Commission will notify the employer’s representative a claim has been filed. The employer’s representative shall immediately contact the claimant.

HISTORY: Amended by State Register Volume 21, Issue No. 4, eff April 25, 1997; State Register Volume 34, Issue No. 2, eff February 26, 2010.