SELF INSURED EMPLOYER'S REQUEST FOR DENIAL OF CLAIM (Insert claimant name and address) Firm Number Claim Number Date of Notice
Dear We received your claim for benefits for your injury or occupational disease of _______________. We are asking the Department of Labor and Industries to reject your claim for the following reason(s):
Only the Department of Labor and Industries can reject your claim. After they review your claim, the department will issue an official order rejecting or allowing your claim. If you disagree with that order, you can send a written request to the Department asking them to review their decision. You may also appeal to the Board of Industrial Insurance Appeals. THIS LETTER DOES NOT OFFICIALLY REJECT YOUR BENEFITS.
(Firm Name) By (insert name) (insert phone number) cc:
Department of Labor & Industries , Attending Physician (insert AP name) File
RESET
F207-163-000 (SIF-4) self insured employer's request for denial of claim 10-2008