Indiana Application For Adjustment of Claim For Provider Fee
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APPLICATION FOR ADJUSTMENT
OF CLAIM FOR PROVIDER FEE

WORKER’S COMPENSATION BOARD
402 West Washington Street, Room W196
Indianapolis, IN 46204-2753
Telephone: (317) 232-3808

State Form 18487 (R6 / 5-11)
Approved by State Board of Accounts, 2011

INSTRUCTIONS:

FOR STATE USE ONLY

1. The applicant must file an original and two (2) copies of this application for it to be processed.
2. Mail to the Worker’s Compensation Board at the above address.
3. For detailed instructions, go to www.in.gov/wcb/files/Provider_Memo.pdf.

Application number

PLAINTIFF vs DEFENDANT
Name of plaintiff (provider)

Name of defendant (employer)

Address (number and street)

Address (number and street)

City, state, and ZIP code

City, state, and ZIP code

Telephone number

(

)

Federal identification number

Name of attorney (must complete)

Federal identification number

Telephone number

(

vs

)

Insurance claim number

Name of insurance carrier

Address (number and street)

Address (number and