I hereby authorize LexisNexis® Risk & Information Analytics Group acting as an agent for ___________________________________________
to review and/or receive copies of any or all parts of compensation claim files(s). I understand this authorization
will include release of information covering both pending and closed cases involving any work related injuries on file.
ScreenNow is a registered trademark of LexisNexis® Risk & Information Analytics Group
To be completed by EMPLOYER:
Date of request:___________________________________________
Signature of requester:___________________________________________
Employer's Full Name:___________________________________________
Employer's Street Address:___________________________________________
Employer's City, State and Zip Code:___________________________________________
To be completed by EMPLOYEE:
Employee's Social Security Number:___________________________________________
Employee's Date of Birth:___________________________________________
Employee's Full Name:___________________________________________
Employee's Street Address:___________________________________________
Employee's City, State and Zip Code:___________________________________________
Signature of Employee:___________________________________________
Subscribed and sworn before me, in my presence, this ________ day of ____________________
19, ____, a Notary Public in and for the state of ______________________________________.
_______________________________________
(Signature of Notary Public)
My Notary Commission expires ________________, 19_____.
Note: This information is not to be used in a manner which would violate the Americans with Disabilities Act.
LexisNexis Form-WC2
Revised 01/27/2009
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LexisNexis Risk & Information Analytics Group Inc. All rights reserved.
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