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NOTICE OF DENIAL OF BENEFITS
State Form 53914 (4-09)

WORKERS COMPENSATION BOARD 402 West Washington Street, Room W196 Indianapolis, IN 46204-2753

* This agency is requesting disclosure of Social Security Number in accordance with IC 22-3-4-13; disclosure is voluntary and you will not be penalized for refusal.

INSTRUCTIONS:

1. Notice of Denial of Benefits must be made in writing and mailed not later than thirty (30) days after the employers knowledge of the injury. (IC 22-3-3-7) 2. Mail to the Workers Compensation Board at the above address.
Accident number

Date of injury (month, day, year)

CLAIM INFORMATION
Name of employer Address (number and street, city, state, and ZIP code) Name of insurer Address (number and street, city, state, and ZIP code) Name of adjuster / case manager Name of employee Address (number and street, city, state, and ZIP code) Telephone number E-mail address Telephone number E-mail address Social Security Number * Insurer claim number Federal identification number Telephone number

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NOTICE OF DENIAL Claim deemed not compensable, no compensation paid.
Explanation

EMPLOYER CERTIFICATION Employer must sign below to certify service of this notice.
Signature of employer Printed name Date (month, day, year) By:

US Mail

Personal service