Free Microsoft Word - BI-115 - West Virginia

Application for Permanent Total Disability Benefits

Return completed form to: American Mining Claims Service P.O. Box 660988 Birmingham, AL 35266-0988

PLEASE REVIEW THE INSTRUCTIONS AND COMPLETE ALL FIELDS BELOW
Please be advised that any person desiring consideration must have: Been awarded the sum of 50% in prior permanent partial disability awards; Suffered a single occupational injury or disease which results in a finding by American Mining Claims Service that a medical impairment of 50% exists; or have Sustained a 35% statutory disability. All of the information contained in this application for benefits is necessary to properly adjudicate the request. Failure to complete all questions on this application may cause substantial delay and possible rejection for consideration, which may affect your rights to benefits in the future. Any incomplete application will not be accepted and will be returned for complete information. 8 After completion, please forward this application for benefits and any supporting evidence to: American Mining Claims Service, P.O. Box 660988, Birmingham, AL 35266-0988

1. Personal Information Name Address City, State, Zip Phone (include area code) 2. Present Employment Status: Employed Unemployed

Social Security Number Date of Birth Most Recent Date of Injury County of Residence Self- Employed Off Due to Injury / / Did you contribute? Did you contribute? Yes No Yes Yes No No Retired

PLEA SE TYPE OR PRI NT WITH A BLA CK OR BLUE BA LLPOINT PEN

3. Are you receiving any of the following retirement benefits? Yes No Check any that apply. Social Security Employer-Funded Self-Funded Date Benefits Started: / 4. Are you receiving any of the following disability benefits? Yes No Check any that apply. Social Security Employer-Funded Self-Funded Date Benefits Started: / 5. Are you receiving any income from other sources not listed above? Describe benefit and onset. (Retirement, pension, etc.) Benefit: Benefit: Onset: Onset: / / / /

6. Is there a pending civil action in any of your AMCS claims that has been brought by you or on your behalf? 7. Dependent Information: Please list all dependent information below. Dependent Social Security Number Date of Birth

If yes, please attach a copy. Relationship

8. Please list all American Mining Claims Service claims and any impairment rating (%) that may have been awarded. Attach additional pages as necessary. Claim Number PPD % Date of Injury Body Part(s)

9. List all disability claims you have filed with other state or federal agencies (include Social Security, veteran's and workers' compensation from other states). Attach additional pages as necessary. Please include a copy of the decision granting benefits.

10. List any non work-related conditions for which you have received treatment in the past 10 years. Include the name, address and telephone number of the treating physician, clinics or hospitals that treated you. Attach additional pages as necessary.

11. List all prescription medications you are taking and include the name of the prescribing physician. Prescription Medication Prescribing Physician Prescription Medication

Prescribing Physician

12. Rehabilitation: List all vocational rehabilitation services you have received because of a work -related condition (job placement, retraining, etc.) Services Received Service Provider Dates of Services

13. Employment History: Please complete your employment history beginning with the most recent and continue in reverse order. Begin Date End Date Employer's Name / / / / / / / / / / / / / / / / / / / / / / / /

Employer's Address

14. List job titles you have held and any specialized training you received to perform these jobs. Job Title Duties / Training Received

Date(s) of Training

15. Educational Background: Please list the names of all schools you have attended. This should include public, private, vocation or colleges and universities. Please include date of attendance and highest degree attained. School Name Location Program Dates Attended Degree / Result

16. Did you receive a GED?

Yes Yes

No

If yes, date of completion: No If yes, dates of service: From

/ /

/ / to Training / Duties / /

17. Have you served in the military?

18. If yes, please list the specific military branch, the highest rank attained and any special duties or training received. Branch Highest Rank Attained

I certify the statements and answers set forth in this document are true and correct to the best of my knowledge. I am aware the law, generally, Chapters 23 and 61 of the WV Code, and specifically, § 61-3- 24f, provides for severe penalties if I knowingly certify a false report or statement and/or withhold a material fact regarding any information requested by American Mining Claims Service. I acknowledge the provisions of the aforemenetioned code and the severe penalties for knowingly and with fraudulent intent aiding or abetting anyone in securing or attempting to secure benefits to which he or she is not entitled.

Signature

Date

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