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BRB No. 120538
VICTORIANO VENTURA))
Claimant))
v.)
)
MARIO, LIMITED) DATE ISSUED: 10/31/2012)
EmployerPetitioner))
HEADRIGHT INSURANCE COMPANY))
CarrierRespondent) ORDER
Employer appealed the administrative
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How to fill out brb no 12-0538 victorino
How to fill out brb no 12-0538 victorino
01
To fill out BRB No 12-0538 Victorino, follow these steps:
02
Start by entering the title of the form, which is 'BRB No 12-0538 Victorino'.
03
Fill in the personal information section at the top of the form, including your full name, contact information, and social security number.
04
Move on to the next section, which requires details about your employment history. Provide information about your current and previous employers, including the company names, addresses, and dates of employment.
05
Proceed to the injury information section. Describe the circumstances of your injury or illness, including the date, time, and location of the incident.
06
If applicable, provide details about any witnesses to the incident.
07
Next, provide information regarding any medical treatment you have received for your injury or illness. Include the names of healthcare providers, dates of treatment, and a brief description of the services received.
08
If you have any pre-existing medical conditions that may be relevant to your claim, mention them in the appropriate section.
09
Complete the employment and earnings section by providing details about your average weekly wage, including any overtime or bonuses you usually receive.
10
In the final section, sign and date the form to certify its accuracy.
11
Make a copy of the completed form for your records and submit the original as instructed in the accompanying guidelines.
Who needs brb no 12-0538 victorino?
01
BRB No 12-0538 Victorino is needed by individuals who have suffered an injury or illness related to their employment. This form is used to file a claim for benefits under the Longshore and Harbor Workers' Compensation Act (LHWCA) administered by the Benefits Review Board (BRB). It is generally required for individuals working in maritime industries or those engaged in activities on navigable waters. If you fall in this category and have experienced an employment-related injury or illness, you would need to fill out this form to initiate the claims process.
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