APPLICATION FOR FIRST RESPONDER PRESUMED COVERAGE FUND Michigan Department of Licensing and Regulatory Affairs Workers' Compensation Agency P.O. Box 30016, Lansing, MI 48909 1. NAME OF EMPLOYEE (Last, First, MI) 4. STREET NUMBER AND NAME 5. CITY 9. SEX Male Female 12. RELATIONSHIP TO EMPLOYEE 13. BIRTH DATE 11. NAME OF DEPENDENTS 6. STATE 7. ZIP CODE 2. SOCIAL SECURITY NUMBER 8. TAX FILING STATUS A. Single B. Single, Head of Household 10. DATE OF DEATH (If Applicable) C. Married, Filing Joint D. Married, Filing Separate 3. DATE OF BIRTH 14. NAME OF EMPLOYER 16. FEDERAL I.D. NUMBER (If Known) 18. STREET ADDRESS 22. IS THIS EMPLOYER A FULLY PAID FIRE DEPARTMENT OR PUBLIC FIRE AUTHORITY? ARE YOU IN FULL TIME ACTIVE SERVICE OF THIS EMPLOYER? 15. DATES OF EMPLOYMENT FROM: 17. EARNINGS 19. CITY YES YES TO: Hourly 20. STATE Weekly 21. ZIP CODE NO NO $ IF NO, PLEASE EXPLAIN:__________________________________________________________________________________________________________________________ BRIEF JOB DESCRIPTION:_________________________________________________________________________________________________________________________ NAME OF SUPERVISOR ____________________________________ PHONE_________________________ EMAIL (if known)________________________________________ 23. IN THE COURSE OF YOUR EMPLOYMENT WITH THE FIRE DEPARTMENT/FIRE AUTHORITY WERE YOU EXPOSED TO THE HAZARDS INCIDENTAL TO FIRE SUPPRESSION, RESCUE, OR EMERGENCY MEDICAL SERVICES? NO YES 24. HAVE YOU FILED A CLAIM AGAINST THE EMPLOYER IN NUMBER 14? 25. HAVE YOU FILED AN APPLICATION FOR MEDIATION OR HEARING (WC104A) AGAINST THE EMPLOYER IN NUMBER 14? YES YES NO NO 26. HAVE YOU BEEN DIAGNOSED WITH RESPIRATORY TRACT, BLADDER, SKIN, BRAIN, KIDNEY, BLOOD, THYROID, TESTICULAR, PROSTATE, OR LYMPHATIC CANCER? YES NO IF YES, TYPE:___________________________________________________ DATE OF INITIAL MEDICAL APPOINTMENT RELATED TO DIAGNOSIS:___________________________ DATE OF DIAGNOSIS:___________________________________ 27. FATHER MOTHER ALIVE (AGE____) ALIVE (AGE____) DECEASED (AGE_____) DECEASED (AGE_____) UNKNOWN UNKNOWN CAUSE OF DEATH:__________________________________________ CAUSE OF DEATH:__________________________________________ YES NO UNKNOWN UNKNOWN 28. ARE YOU CURRENTLY OR HAVE YOU EVER BEEN A TOBACCO USER? If Yes, proceed to the following: AT WHAT AGE DID YOU FIRST USE TOBACCO?______________________________________ IF YOU HAVE QUIT, PLEASE PROVIDE DATE________________________________________ PLEASE DESCRIBE TOBACCO USE____________________________________________________________ ___________________________________________________________________________________________ 29. ARE YOU RECEIVING A PENSION? IF YES, PLEASE ADVISE THE TYPE OF PENSION: REGULAR OR DISABILITY (circle one) IF NO, HAVE YOU APPLIED FOR A PENSION? HAS YOUR PENSION APPLICATION BEEN DENIED? YES YES YES NO NO NO WC-272 (2/17) Front American LegalNet, Inc. www.FormsWorkFlow.com 30. LIST THE NAMES AND ADDRESSES OF ALL DOCTORS, HOSPITALS AND OTHER HEALTH CARE PROVIDERS. (ATTACH A SEPARATE SHEET IF NECESSARY) NAME ADDRESS (Street Number and Name) CITY STATE ZIP CODE 31. HAVE YOU HAD ANY EMPLOYMENT SINCE THE DATE OF INJURY? IF YES, LIST THE NAME AND ADDRESS OF THE EMPLOYER. YES NO THE FILING OF THIS APPLICATION CONSTITUTES A SUSPENSION OF MY CLAIM AGAINST MY EMPLOYER. The submission of this application does not guarantee the right to benefits under the Workers' Disability Compensation Act. SIGNATURE OF EMPLOYEE ATTORNEY IDENTIFICATION NAME OF ATTORNEY TELEPHONE NUMBER EMAIL ADDRESS DATE Making a false or fraudulent statement for the purpose of obtaining or denying benefits can result in criminal or civil prosecution, or both, and denial of benefits. NAME OF LAW FIRM ATTORNEY ID P. ADDRESS (STREET NUMBER AND NAME) CITY STATE ZIP CODE SIGNATURE OF ATTORNEY TELEPHONE NUMBER DATE LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. AUTHORITY: Workers' Disability Compensation Act COMPLETION: Mandatory MCL 418.405 PENALTY: None Please make sure you meet all of the following requirements before submitting this application: · Be a member of a fully paid fire department or public fire authority and be compensated on a full-time basis, · Be in active service of the department or authority for at least 60 months, · Be diagnosed with any respiratory tract, bladder, skin, brain, kidney, blood, thyroid, testicular, prostate, or lymphatic cancer, · Be employed in the active service of the department or authority at the time the cancer manifests itself, and be exposed to the hazards incidental to fire suppression, rescue, or emergency medical services in the performance of his or her work-related duties, · First apply for and do all things necessary to qualify for any pension benefits to which you may be entitled. If you have been denied or ineligible please provide documentation. WC-272 (2/17) Back American LegalNet, Inc. www.FormsWorkFlow.com