FOR ALL FILE COPY REQUESTS:  This form must be completed and placed on the spindle in the claim file.


Employee Name: __________________________________


File Number:   __________________________________


Assigned Claims Examiner:__________________________________


Date of Request for File

Copy:                   __________________________________


Name of Requestor:      __________________________________


File Copy to be Sent to:__________________________________


Initial Reviewer Name:  __________________________________


Initial Review Date:    __________________________________


Final Reviewer Name:    __________________________________


Final Review Date:      __________________________________



I have carefully reviewed the documents and/or electronic media being sent pursuant to this claimant request for a copy of file documents.  To the best of my knowledge these documents and/or electronic media does not contain Personally Identifiable Information (PII) or any PII has been redacted.




_________________________________________   ___________

(CE, CE2, FAB, or NO Representative)       (Date)




_________________________________________   ___________

(Final Reviewer)                           (Date)