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APPLICATION FOR HEARING



Vs





WC #-###-###-##
A. Application for Hearing

Name of Party



Hearing Issues (At least 1 must be checked)











Witnesses to be called at the hearing or by deposition (List names and addresses)







B. Request for the OAC to Set the Matter for Hearing Rule 8(H) OACRP:

Do not fill out Section C. Complete Sections D and E.

Case Name

Company

Claimant Name




C. Signature
Please type your name in the box below.  By typing your name, you certify this information is accurate and certify that this will act as your binding electronic signature. 











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D. Certificate of Mailing

I hereby certify that I mailed or delivered the original of the Applicaion for Hearing and Notice to Set to all parties at the addresses shown below (A claimant must provide a copy to the employer and the insurer, or their attorney):

Opposing Party 1 or their Representative









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Opposing Party 2 or their Representative









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Please type your name in the box below.  By typing your name, you certify this information is accurate and certify that this will act as your binding electronic signature.


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