PRIOR INJURY QUESTIONNAIRE WSI HelpLine 1-800-777-5033 Questions? Call us. Report Injuries Immediately. WORKFORCE SAFETY & INSURANCE CLAIMS DIVISION SFN 7208 (05/2003) ND Fraud and Safety Hotline 1-800-243-3331 Report Fraud and Unsafe Work Conditions. 1600 EAST CENTURY AVENUE, SUITE 1 PO BOX 5585 BISMARCK ND 58506-5585 TELEPHONE NUMBER (701) 328-3800 FAX NUMBER (701) 328-3820 OR TOLL FREE FAX 1-888-786-8695 TDD NUMBER (for the hearing impaired only) (701) 328-3786 www.WorkforceSafety.com PLEASE PRINT OR TYPE USING BLACK OR BLUE INK Claim Number Social Security Number Injury Date Birth Date Sex F M Marital Status Single Married Injured Worker’s Name Injured Worker’s Address YOU MUST ANSWER THE FOLLOWING QUESTIONS: 1. What part of your body did you injure at work? ___________________________________________________________ 2. Before this injury, have you ever had any injuries or health problems, work related or not, to the area of your body as indicated in #1? Yes No If yes, please explain: ___________________________________________________ _________________________________________________________________________________________________ 3. If yes to #2, please list any medical doctor, chiropractor, physical therapist or other health care professional that you treated with. Please list any additional providers on the backside of this form. Medical Provider Name Address Date 4. Have you ever filed any other workers compensation claims, in any state, for any injuries or health problems to any area of No If yes, in what state(s)? _______________________________________________________ your body? Yes Body part(s): ______________________________________________________ 5. Have you ever received a permanent disability, impairment, or percentage rating for any injury or health problem? Yes No If yes, list body part(s): ________________________________________________________________ No 6. Were you ever unable to work because of an injury or health problem? Yes If yes, for how long? Body part(s): _______________________________________________ 7. Before this injury, has any doctor or medical provider told you to avoid certain physical activities because of an injury or No If yes, complete the following: health problem? Yes Body Part Restriction Doctor Who Initiated Restriction To Dates From To From 8. Explain the limits any prior injuries or health problems have had on your current daily activities: By signing this form, I acknowledge that I have read the Fraud Warning on the reverse side of this form and understand that falsifying this claim or making a false statement regarding this claim may be a felony punishable by substantial fines and imprisonment. By my signature below, I declare that the statements on this form are true and accurate C16 Signature Date American LegalNet, Inc. www.FormsWorkflow.com FRAUD WARNING - PENALTY FOR FILING FALSE CLAIMS WITH WORKFORCE SAFETY & INSURANCE (WSI). Any person claiming benefits or compensation from WSI who files a false claim, or makes a false statement, or fails to notify WSI as to the receipt of income or an increase in income from employment, in connection with any claim or application for workers compensation benefits will FORFEIT ANY FUTURE BENEFITS and may be GUILTY OF A FELONY which is punishable by IMPRISONMENT, SUBSTANTIAL FINES, OR BOTH. These criminal penalties are applicable to ALL PERSONS dealing with the Fund, including INJURED WORKERS, EMPLOYERS, MEDICAL PROVIDERS, AND ATTORNEYS. I ACKNOWLEDGE, by my signature on the front of this form, THAT I HAVE READ AND UNDERSTAND THE ABOVE DESCRIPTION OF THE PENALTIES FOR SUBMITTING A FALSE CLAIM FOR BENEFITS OR MAKING FALSE STATEMENTS TO WSI. I understand that WSI is relying upon the truth of my statements in awarding benefits or providing services on this claim. I CERTIFY THAT I HAVE NOT FILED A FALSE CLAIM, NOR MADE ANY FALSE STATEMENT, NOR KNOW OF ANY FALSE STATEMENT, MADE IN CONNECTION WITH THIS CLAIM FOR BENEFITS WITH WSI. American LegalNet, Inc. www.FormsWorkflow.com