Request For Assistance Form C40a Page 2
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2FORM C40A
E) WORKERS’ COMPENSATION INSURANCE COMPANY:
Company Name: __________________________________________________________
Street Address: ___________________________________________________________
City: ______________________________ State: __________ Zip: _________________
Adjuster’s Name: __________________________________________________________
Telephone: __________________________
Fax: _____________________________
Email Address: ___________________________________________________________
F) BRIEF DESCRIPTION OF INJURY:
Nature of Injury (carpal tunnel, broken arm, etc.)__________________________________
How injury occurred (fell, lifting, driving, etc.) ____________________________________
________________________________________________________________________
When did Employee report injury to employer? __________________________________
To Whom? _________________________ Person’s Title: _________________________
How long has Employee worked for employer? __________________________________
County of Injury: __________________________________________________________
G) MEDICAL TREATMENT:
Was Employee given a choice of three (3) or more treating doctors? _________________
If a panel was provided, which doctor was selected? _____________________________
(Please attach all relevant records resulting from medical treatment for this injury.
Failure to do so may result in resolution of your request being delayed.)
H) DESCRIBE COMPLAINT OR REASON FOR REQUEST:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
For faster service, you may send your completed form directly to the local office that will handle your request.
You can find a map of the offices along with addressees and phone numbers by checking our website at
I hereby request the Department of Labor and Workforce Development to assist in any disputed workers’ compensation
issues related to the above-detailed injury. I also authorize the Department of Labor and Workforce Development to contact
any person who has information regarding that injury. If the undersigned is the Injured Employee or the Injured Employee’s
legal representative, authorization is also given to the Department of Labor and Workforce Development to use the Injured
Employee’s social security number in any manner necessary to provide the requested assistance.
DATE: ___________________________
____________________________________________
SIGNATURE OF REQUESTING PARTY
_____________________________________
PRINTED NAME OF REQUESTING PARTY
REQUEST FOR ASSISTANCE form must be signed by Requesting party or authorized representative.
LB-0381 (REV. 04/09)
Pg 2 of 2
RDA 10183
American LegalNet, Inc.
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