Fill and Sign the Request for Assistance for Workers Compensation Indiana Form

                                                                                  Currently receiving benefits       Benefits have been terminated                   Have never received benefits                              ( ) ( ) ( ) REQUEST FOR ASSISTANCEState Form 45442 (R / 11 -94) Please complete and return to:WORKER'S COMPENSATION BOARDATTN: Ombudsman Division 402 West Washington Street, Room W196 Indianapolis, Indiana 46204 PLEASE PRINT OR TYPE Indiana Worker's Compensation Board Ombudsman Division (317) 232-59221-800-824-COMP EMPLOYEE INFORMATION EMPLOYER INFORMATION Name of employee Name of employer Address (number and street) Address (number and street) City, state, ZIP code City, state, ZIP code Telephone number Telephone number Social Security number * County of employment Date of accident (month, day, year) WORKER'S COMPENSATION INSURANCE COMPANY INFORMATION Check one: Name of company Address (number and street) Date of termination (month, day, year) City, state, ZIP code Telephone number Have you hired an attorney? ** Contact person(s) If Yes, name and telephone number of attorney Briefly describe your complaint / dispute (attach additional sheets if necessary): I hereby request the Ombudsman Division of the Worker's Compensation Board to investigate my complaint. I understand that the Ombudsman Division isnot a replacement for legal counsel, and that any specific legal questions should be addressed to my attorney. Signature of employee Date (month, day, year) * PRIVACY NOTICE: This agency is requesting disclosure of your Social Security number in accordance with IC 22-3-4-13. This disclosure is not mandatoryand you will not be penalized for refusing.** You have no obligation to employ legal counsel under the Indiana Worker's Compensation and Occupational Diseases Acts.