Fillable Printable Form 207-163-000

Form 207-163-000

F207-163-000 (SIF-4) self insured employer’s request for denial of claim 10-2008

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