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Fill and Sign the Claimant Attorney Fees in Wv Workers Compensation Cases Form

Fill and Sign the Claimant Attorney Fees in Wv Workers Compensation Cases Form

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OFFICE OF JUDGES REQUEST FOR AWARD OF CLAIMANT’S ATTORNEY FEES and EXPENSES WV Code §23-2C-21(c) CLAIMANT’S NAME: ____________________________ SSN: _____-____-______ DOI:__________________ Cl.# ________________ OOJ Case ID#__________________ EMPLOYER: ____________________________ DATE OF CLAIM ADMINISTRATOR’S “UNREASONABLE” ORDER : ___________________ REVERSED BY: DATE REVERSED: ___________________ □ Office of Judges □ Board of Review (attach decision) □ Supreme Court (attach mandate) Submitted by (please print): __________________________ Bar ID#_______________ Address: ____________________________________________________ Date Form Submitted: __________________________ cc:

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