Form 9 Wca-1 - Memo Of Denial Of Workers' Compensation Benefits printable pdf download

Form 9 Wca-1 - Memo Of Denial Of Workers' Compensation Benefits

Memo of Denial of Workers’ Compensation Benefits

Claimant’s Name ___________________________ Social Security No. _________________________

Employer __________________________________ Identification No. __________________________

Date of Accident ____________________________ Date First Report Received ___________________

YOUR CLAIM TO WORKERS’ COMPENSATION BENEFITS IS HEREBY

DENIED BY EMPLOYER OR CARRIER FOR REASONS INDICATED

BELOW. IF YOU SO ELECT, YOU MAY PETITION THE

COMMISSIONER OF LABOR, 95 PLEASANT ST., CONCORD NEW

HAMPSHIRE, 03301, IN WRITING FOR A HEARING. YOU MUST

REQUEST A HEARING WITHIN 18 MONTHS OF THE DENIAL.

REASONS

No Employer-Employee Relationship (pars. VII, VIII, IX, RSA 281-A:2)

No Causal Relationship to Employment (pars. XI, XIII, RSA 281-A:2)

Employee’s Fault (RSA 281-A:14)

Improper Notice of Injury by Employee (RSA 281-A:19, 20, 21)

Explanation

____________________________________________________________________________________

Authorized Representative______________________________________________________________

Insurance Carrier and Number___________________________________________________________

Carrier’s Address and Phone #___________________________________________________________

Date_________________________

9 WCA-1 (9-02)

White – Labor Dept.

Canary – Insurance Claims Office

Pink – Employee’s Copy

Form 9 Wca-1 - Memo Of Denial Of Workers' Compensation Benefits