Free 51247.PDF - Indiana

Accident Number

Indiana Worker's Compensation Board Application for Second Injury Fund Benefits
State Form 51247 (2-03) Instructions: This form must be submitted in duplicate to: Indiana Workers Compensation Board 402 W. Washington, RM W196, Indianapolis, IN 46204-2753

PRIVACY NOTICE
*This agency is requesting disclosure of your Social Security number in accordance with IC 22-3-4-13. This disclosure is not mandatory and you will not be penalized for refusing.

CLAIMANT INFORMATION
Social Security Number * Address State Zip Phone ( ) Date of Birth Last Name City First Middle

INJURY INFORMATION
Date of Injury Disputed Cause # Date of Award Type of Injury/Illness Part of Body

Briefly describe the injury in your own words

¨ Check here if you have received any second injury fund payments for this accident.

CLAIMANT'S AFFIDAVIT As the injured party requesting benefits of the second injury fund administered by the Indiana Worker's Compensation fund, I do hereby solemnly swear and affirm that the information given in this application is a true and accurate representation of the information regarding my work-related injury, as witnessed on this ___________day of ___________________, two thousand and _____________________. Notary Seal Notary Signature Applicant Signature

Notary Printed Name

Applicant Printed Name

Notary Commission Expiration Date

Date Prepared

APPLICATION CHECKLIST In order to proceed in processing this application, The Board must receive from you the following items (Please Check): ¨ This completed application is signed and notarized ¨ A current copy of the applicant's medical report. ¨ Form submitted in duplicate