Application For Disability Relief {BWC-3527}

Application for Handicap Reimbursement Under the Ohio Revised Code Section 4123.343, BWC uses this application to determine the percentage of compensation to properly charge to, or to refund from, the Statutory Surplus Fund due to an aggravation of one or more of the pre-existing conditions below: 01 02 03 04 05 06 Epilepsy Diabetes Cardiacdisease Arthritis Amputatedfoot,leg,armorhand Lossofsightofoneorbotheyesor partiallossofuncorrectedvisionof morethan75percentbilaterally Residualdisabilityfrom poliomyelitis Cerebralpalsy Multiplesclerosis Parkinson'sdisease 11 12 13 14 Cerebralvascularaccident Tuberculosis Silicosis Psycho-neuroticdisabilityfollowing treatmentinarecognizedmedicalor mentalinstitution Hemophilia Chronicosteomyelitis Ankylosisofjoints HyperInsulinism Musculardystrophies Arterio-sclerosis Thrombo-phlebitis 22 23 Varicoseveins Cardiovascularand pulmonarydiseasesofaireighter employedbymunicipalcorporationor townshipasaregularmemberofalawfully constitutediredepartment Coalminerspneumoconiosis Disabilitywithrespecttowhichanindividual hascompletedarehabilitationprogramfora previousinjuryorclaim (ORC4121.61-69) Serviceconnectedinjury (seeORC4123.63) 07 08 09 10 15 16 17 18 19 20 21 24 25 26 Attachments 1. Medicalevidence(intheformofdoctor'sreports,diagnostictestssuchasanMRI,X-RAY,orCTScan,laboratory records)thattheemployeesufferedfromoneormoreoftheconditionslistedabove. 2. Evidencethattheconditionconstitutedahandicapwithinthemeaningofthelaw,includingbutnotlimitedto evidencethatprior totheinjury,diseaseordeath,thehandicapconditioncausedtheemployeetobehospitalized ortoobtainextensivemedicaltreatment. 3. Evidencethattheinjury,disease,death,orthehandicapconditioncausedtheemployeetobeabsentfromwork foratleasteightormoreconsecutivedaysorresultedinascheduledlossunderR.C.4123.57(B). 4. Evidenceintheformofafidavitsormedicalreportstosupportthecontentionthattheinjury,diseaseordeath would not have occurred but for the pre-existing handicap condition of the employee or that the resulting disabilityordeathwascaused,inpart,throughaggravationofthehandicappedcondition. 5. UnderBWCrules,iftheapplicationisnotaccompaniedbyallrelevantmedicalevidenceandsubstantialproof, theAdministratormaydismisstheapplication. Filing instructions ·Youmayhanddeliverthisapplicationto: BWC, Customer Service, 30 W. Spring St., Columbus, OH, Second Floor. ·Youmaymailthisapplicationto:BWC, Attn: Handicap Reimbursement Unit, 30 W. Spring St., 26th Floor, Columbus, OH 43215-2256. Ifyouprovideacopyoftheapplicationandaself-addressedstampedenvelope,BWCwillmaila date-stampedcopytotheemployerrepresentative.Note:Youmaysendane-mailwithanyquestionsconcerningtheHandicap ReimbursementProgrambyusing:HandreimbQuest@bwc.state.oh.us To be completed by employer or employer representative Injured worker name Nature of handicap History of injury Social Security number Date of injury Claim number Date of death Allowed condition(s) in this claim State how the pre-existing handicap increased the cost of this claim (Stapleattachallforms)Note: The administrator will not consider applications lacking a sufficient description concerning the handicapped condition's impact on the occupational injury, disease or death. The administrator will make a determination based on the information contained in this application. Type of compensation Do you request an informal conference TemporaryTotal Inperson WagesinlieuofTT (attach proof) Byphone R.C.4123.57(B) (scheduled loss) Contactname PermanentTotal Death Fill out information below completely Employer name Address City Employer representative name Address City State Nine-digit ZIP code Risk number Manual number Telephone number ( ) State Nine-digit ZIP code Docketing (contact name) www.FormsWorkFlow.com