Document DgvnXKx711GpJNmVDEg8xnzM

State of Ohio BUREAU OF WORKERS' COMPENSATION NOTICE OF FILING APPLICATION FOR DETERMINATION OF AWARD Claimant's Address (9&** jSW? r(jlpt. riVFW You are hereby notified that the above named claimant has filed with the BUREAU OF WORKERS' COMPENSATION an application for the purpose of having a determination made as to the amount of compensation, etc., to be paid in the above numbered case under the provisions of the Workers' Compen sation Act. A copy of the application together with the proof submitted in support thereof is enclosed. Please advise whether you accept and recognize the allegations set forth therein and will make payments therefore. If we do not receive an answer from you by , or you answer that you refuse acceptance, the claim will be scheduled for a formal hearing before a District Hearing Officer. If this situation occurs, you will be notified of the date, time, and place of the hearing. An answer or refusal must be accompanied by proof in support of your position. The answer and proof must be filed in dupli cate. Proof may be submitted in the form of affidavits or depositions. BUREAU OF WORKERS' COMPENSATION JAN 1 9 1989 GENC 002824