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



Claim File Employee Name:       ____________________________________


Claim File Employee SSN:        ____________________________________


Assigned Claims Examiner:       ____________________________________


Date of request for file copy:     ____________________________________


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.




_________________________________________          ___________

(Claims Examiner or Hearing Representative)                         (Date)



_________________________________________           ___________

(Senior Claims Examiner  )                                                     (Date)