Free 01042.PDF - Indiana

APPLICATION FOR REVIEW BY FULL BOARD
State Form 1042 (R3 / 2-98)

Workers Compensation Board 402 W. Washington Street, Room W196 Indianapolis, IN 46204-2753
Application number

INSTRUCTIONS: This application must be filed within 30 days from the date of the award for which review is requested. The application should be filed in triplicate and captioned the same as the original claim for compensation. The application number assigned to the original cause should be shown on this application.

REVIEW BY THE FULL BOARD OF THE ORIGINAL AWARD
Before the Worker's Compensation Board of Indiana: (Name of plaintiff) Name of defendant

VS
Address of plaintiff (number and street, city, state, ZIP code) Address of defendant (number and street, city, state, ZIP code)

The above named ____________________________________________________________________________ respectfully makes application for review by the Full Board of the award as to compensation made in the above captioned cause on the _______________________________ day of ___________________________, 19 _________, based upon, to wit: 1. that said award is not sustained by sufficient evidence; or 2. that said award is contrary to law.

I wish to order a transcript in this matter and ask that the court reporter contact me regarding said transcript. (If you fail to indicate your desire for a transcript here, you must contact the court reporter immediately, as no continuance will be granted for this purpose after the hearing date is set.)
Signature of plaintiff or defendant Signature of attorney

Address of attorney (number and street, city, state, ZIP code)