Application For Determination Of Percentage Of Permanent Partial Disability Or Increase Of Permanenet Partial Disability
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Application For Determination Of Percentage Of Permanent Partial Disability Or Increase Of Permanenet Partial Disability Form. This is a Ohio form and can be use in Injured Workers Workers Comp.
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Tags: Application For Determination Of Percentage Of Permanent Partial Disability Or Increase Of Permanenet Partial Disability, BWC-1214, Ohio Workers Comp, Injured Workers
APPLICATION FOR DETERMINATION
OF PERCENTAGE OF PERMANENT PARTIAL
DISABILITY or INCREASE
OF PERMANENT PARTIAL DISABILITY
Better Workers’ Compensation
Built with you in mind.
INSTRUCTIONS:
• Please use a typewriter or ballpoint pen and press firmly to complete this form.
• You or your representative must sign this form before submission.
• You must submit three copies and retain one copy for your records.
• If assistance is needed you may contact your local BWC customer service office.
Claim
number
Application for:
Determination of the initial percentage of permanent partial disability (%PPD)
Determination in the %PPD for a newly allowed condition in this claim (no new medical required)
Increase in the %PPD – I believe that the percentage of permanent partial disability has increased over the
percentage previously determined. I have attached three copies of the medical report from my doctor to
support this application. Medical reports attached are accompanied by evidence of new and changed
circumstances.
PART A – INJURED WORKER INFORMATION
Injured worker name
Date of injury
Social Security Number
Address
State
City
County
Work telephone number
(
)
9-digit ZIP Code
Home telephone number
(
)
PART B – APPLICATION INFORMATION
Telephone number
(
)
Employer at the time of injury
Address
State
City
9-digit ZIP Code
Describe the disability which you now consider to be permanent as a result of your injury or occupational disease. How does this injury or occupational
disease affect your activities of daily living? (specify parts of the body affected)
Other workers' compensation claim numbers and the nature of each injury or occupational disease are listed below.
CLAIM NUMBER
ALLOWED CONDITION
CLAIM NUMBER
1.
5.
2.
6.
3.
7.
4.
ALLOWED CONDITION
8.
PART C – AUTHORIZATION
Name of injured worker representative (if represented) (please print or type)
REP I.D. number
Signature of injured worker / injured worker representative (if represented)
Date
I hereby authorize the BWC/employer to forward any monetary award generated by this application to the attorney
indicated above for disbursement to me.
Signature of injured worker
Date
BWC USE ONLY
Date mailed
Copy mailed to:
Employer
White–Claim file
Employer representative
Canary–Employer
Pink–Employer representative
Goldenrod–Injured worker
BWC-1214 (C-92 and C-92-A combined) (Rev. 5/1/1999)
C-92
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