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To the Industrial Accident Board of the State of Delaware Form

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PETITION TO DETERMINE DISFIGUREMENT To The Industrial Accident Board of the State of Delaware Sitting in and for County Petitioner ) ) vs. ) Case File No. ) ) Employer ) The undersigned petitioner respectfully represents: Being desirous of having a hearing on the ground that has sustained a disfigurement to the following part/parts of the body resulting from a compensable industrial accident which occurred on and became permanent as of , the undersigned respectfully prays that your Honorable Board shall, after due notice of the time and place of hearing served on all parties in interest, hear and determine the matter in accordance with the facts and the law, and state its conclusion of fact and rulings of law. Dated this day of A.D. 20 Name Address Document Control #: C 60-07-12-12-11

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Fill and Sign the To the Industrial Accident Board of the State of Delaware Form