Fill and Sign the Workers Comp Complaint Form West Virginia Offices of the

WEST VIRGINIA INSURANCE COMMISSION SELF INSURANCE WORKERS’ COMPENSATION COMPLAINT FORM NAME (person filing complaint):__________________________________________________ (select one)  CLAIMANT  VENDOR OTHER TELEPHONE:___________________________EMAIL:______________________________ MAILING ADDRESS:___________________________________________________________________ CLAIM NUMBER:_____________________________________________________________ EMPLOYER NAME AND POLICY NUMBER: VENDOR /TPA NAME AND TELEPHONE NUMBER: ______________________________________________________________________________ SELF INSURED EMPLOYERS AD MINISTER THEIR OWN CLAIMS . HAVE YOU CONTACTED THE EMPLOYER OR TPA? YES NO You are encouraged to resolve this issue by contacting the employer or the third party administrator prior to filing a formal, written complaint. IS THIS ISSUE CURRENTLY IN THE APPEAL PROCESS? YES NO HAS THE SUPREME COURT OF APPEALS ISSUED A RULING ON THIS MATTER? YES NO PLEASE NOTE THAT THE WV INSURA NCE COMMISSION CAN NOT INTERVENE IN MATTERS THAT ARE CURRENTLY IN LITIGATION OR OVERTURN RULINGS ISSUED BY ANY LEVEL OF THE APPEAL PROCESS. PLEASE PROVIDE THE REASON FOR YOUR COMPLAINT (Describe the facts and circumstances which form the basis of your complaint. Provide names and telephone numbers if possible. You may attach additional pages if necessary. Attach copies of any relevant correspondence, or documentation that supports your claim and/or complaint). ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ SIGNED:______________________________________________________ DATE:________________ This page for in-house use only REVIEWER INFORMATION REVIEWER: ________________ ________________________ DATE RECEIVED:__________________ _________________ DATE ISSUE RESOLVED: ____________________________ ACTIONS  MAILED COMPLAINT FORM : DATE___________________________  TOOK INFORMATION OVER P HONE: DATE_____________________  CALLS MADE (TO/DATE/TIME/RESULTS) ________________________ __________________________________________ ________________________ __________________________________________ ________________________ __________________________________________ ________________________ __________________________________________ BRIEFLY DESCRIBE ACTIONS AND RESOLUTION TO ISSUE ________________________ __________________________________________ ________________________ __________________________________________ ________________________ __________________________________________ ________________________ __________________________________________ ________________________ __________________________________________ ________________________ __________________________________________ ________________________ __________________________________________ ________________________ __________________________________________ ________________________ __________________________________________ ________________________ __________________________________________ ________________________ __________________________________________ ________________________ __________________________________________ ________________________ __________________________________________ ________________________ __________________________________________ ________________________ __________________________________________