Number and style of proceeding in the court: __________

Decision to be reviewed was rendered by: (Check one)

( ) The Workers' Compensation Commission, or

Date of filing of the decision to be reviewed __________

Date a copy of the decision was sent to the parties__________

Nature of the decision to be reviewed __________

Relief sought: __________

Relief granted: __________

If the Decision to be reviewed is from the Workers' Compensation Commission, also attach a certified copy of the underlying decision of the administrative law judge:

If the Decision to be reviewed is from the Workers' Compensation Court of Existing Claims en banc panel, also attach a certified copy of the underlying decision of the Judge of the Court.

C. Brief Summary of Proceeding. Exhibit “B” attached (not to exceed one 8 1/2 x 11″ double spaced page).

D. Issues and Errors Proposed to be Raised on Appeal. Exhibit “C” attached. (Number and state with specificity each point urged as error.) (General assignments will not suffice.)

ANY RELATED OR PRIOR APPEALS? ___ YES ___ NO

(Identify by style, citation, if any, and Supreme Court Number.)

Date: __________, 20___

Telephone:____________________

I __________, do hereby certify that on this __________ day of __________, 20__________, I filed with the Workers' Compensation Commission or the Workers' Compensation Court of Existing Claims, a correct copy of the Petition for Review with attachment(s), and also mailed a copy with attachment(s) to each party to the proceeding or his counsel of record as follows: