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Get Ic 12 Form 2017-2024

Tative Information Employer s Representative Information Rep ID# Rep ID# Name Name Telephone Fax Telephone Injured Worker Employer BWC Administrator Heard on Fax Appealing Order of: Appealed by: Hearing Location Fax BWC Administrator District Hearing Officer Staff Hearing Officer (city) (mm/dd/yyyy) Date Order Received (mm/dd/yyyy) NOTE: If you are filing an appeal of a staff hearing officer order, failure to identify the necessary documents may result in a determination no.

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