Claim Number: APPLICATION FOR COMPENSATION FOR PERMANENT TOTAL DISABILITY (Use the claim #with the most recent date of injury or diagnosis) 1. Each application for permanent total disability shall identify, if already on file, or be accompanied by medical evidence supporting the application. If documents are already on file, there is no need to resubmit them. a. The medical examination upon which the report is based must have been performed within twenty-four months prior to the date of filing of the application for permanent total disability compensation (document information below). b. If an application for permanent total disability compensation is filed that does not meet the filing requirements of Ohio Adm.Code 4121-3-34, or if proper medical evidence is not filed or identified within the claim file, the application shall be dismissed without hearing. 2. The completed application should be filed at an Industrial Commission office. 3. If permanent total disability is granted, the injured worker is not permitted to return to work in any capacity. Injured Worker's Information Name Address City, State, Zip Telephone Fax Injured Worker's Representative Information Rep ID# Name Telephone Fax Date of Birth Consider All Claims Consider only the injured worker's claim numbers listed below when processing this application (claims with similar body parts will be considered): Claims not listed here will not be considered and cannot be added at the time of your hearing. By not listing a claim, you cannot then argue that the allowed conditions in that claim prevent you from working. This does not preclude future benefits and/or medical treatment for the named conditions in the claim. If you have not checked the "Consider All Claims" box, the Industrial Commission will include all claims containing similar body parts to those conditions in the claims that have been identified. I have attached the required medical documentation to support this application for permanent total disability. Date of Exam Date of Exam (mm/dd/yyyy) Physician Name Physician Name (mm/dd/yyyy) Medical documentation listed below has been previously filed and supports this application for permanent total disability. Claim Claim Claim Date of Exam Date of Exam Date of Exam (mm/dd/yyyy) Physician Name Physician Name Physician Name (mm/dd/yyyy) (mm/dd/yyyy) Medical documentation listed above must opine only on the allowed conditions in the claims you have identified above or the application for permanent total disability will be dismissed. If necessary, please attach additional information. IC2 Page 1 of 6 An Equal Opportunity Employer and Service Provider Timely, impartial resolution of workers' compensation appeals OIC 3012 (Rev. 09/15) American LegalNet, Inc. www.FormsWorkFlow.com Claim Number: MEDICAL HISTORY List all of the physicians you have seen in the last five years, their addresses, and for what condition(s) you have seen them: Physician's Name Physician's Address Condition(s) List all of the surgeries and procedures you have had, beginning with the most recent: Surgery/Procedure Physician's Name Date (mm/dd/yyyy) Do you use any medical equipment such as a cane, brace, walker, wheelchair, oxygen or TENS unit? Yes No If yes, please specify: Do you have any other medical conditions that impact your ability to work? DAILY ACTIVITIES Has your treating doctor told you to restrict or limit your activities due to your injuries? If yes, please specify: Yes No Do you drive a vehicle? Yes No How far can you drive at one time? How long can you stand at one time? How long do you sleep each night? How far can you walk at one time? How long can you sit at one time? IC2 Page 2 of 6 An Equal Opportunity Employer and Service Provider Timely, impartial resolution of workers' compensation appeals OIC 3012 (Rev. 09/15) American LegalNet, Inc. www.FormsWorkFlow.com Claim Number: DAILY ACTIVITIES CONTINUED Are you involved in any organizations, clubs, charities or associations of any kind, either as a volunteer or member? Yes No If yes, please provide name of organization and nature of association: Do you have hobbies or engage in recreational or social activities? If yes, please specify: Yes No Do you dress yourself? Yes Yes No Yes No Need Assistance No Need Assistance Yes No Do you shower or bathe yourself? Do you prepare any meals? Do you do any housework/yardwork (laundry, repairs, grocery shopping, grass cutting etc.)? If yes, please specify: What is the most weight you lift on a daily basis? Describe any other limitations or changes in your lifestyle, if any, resulting from the allowed condition(s) in your claim(s): OTHER DISABILITY BENEFITS Have you ever filed for Social Security Disability benefits? Yes No If you are now, or have ever, received Social Security Disability payments, complete the following section. This does not apply to Social Security Retirement. Starting Date (mm/dd/yyyy) Termination Date (mm/dd/yyyy) What was the reason for termination? Do you receive disability benefits other than Social Security? (i.e.: VA, Fireman & Police Officer Disability, etc.)? Yes No IC2 Page 3 of 6 An Equal Opportunity Employer and Service Provider Timely, impartial resolution of workers' compensation appeals OIC 3012 (Rev. 09/15) American LegalNet, Inc. www.FormsWorkFlow.com Claim Number: VOCATIONAL REHABILITATION HISTORY Have you sought or been offered vocational rehabilitation services? If yes, please explain: Yes No EDUCATION What is the highest grade of school you completed? Where? (School, City) When? (mm/dd/yyyy) Did you graduate from high school? If yes, which curriculum? Yes No Standard College Preparatory Special Education If no, did you receive a certificate for passing the General Educational Development test (GED)? Yes No Why did you end your schooling? Have you gone to trade or vocational school or had any type of training? Yes No If yes, what type of trade school, vocational schooling or special training have you received and when? How has this schooling or training been used in any of the work you have done? Can you read? Can you write? Yes Yes No No If yes, what language(s)? If yes, what language(s)? What languages can you speak? Can you do basic math? Yes Not Well No Do you have basic computer skills (keyboarding; business office software applications such as Microsoft Office; using and creating spreadsheets)? List all software with which you are proficient. WORK HISTORY What is the last date you worked in a