Application for Determination or Increase of Percentage of Permanent Partial Disability (C - 92) BWC - 1214 (C - 92 a n d C - 92 - A combined) (Rev. June 20 , 2018 ) C - 92 Claim number Instructions Complete this form and fax it to 1 - 866 - 336 - 8352, or send it to your local BWC claims office. Injured worker information Name Date of injury Address Preferred method of contat City State ZIP code number Primary email address Application designation I am applying for one of the options listed below. The initial percentage of permanent partial disability (%PPD) I understand I must attend a BWC exam, and that BWC will evaluate all the conditions allowed in my claim unless noted below. Note exc lusions, if applicable, here: I ncrease in the %PPD I believe my medical condition has worsened , and my %PPD for this claim has increased. I understand I am required to submit with this application a medical report from my doctor showing evidence of an increase. I understand BWC will only consider an increase for those conditions supported by evidence of new and changed c ircumstances. I understand if an exam is scheduled, I am required to attend. Exam a vailability : Mornings (7 a . m . to 12 p . m .), afternoons (12 p . m . to 5 p . m . ) We will attempt to accommodate your requested exam availability. WARNING! BWC may dismiss this application if the injured worker fails to respond to an attempt to schedule an exam or fails to attend the exam. Please check all days of the week and times of the day that you can attend an examination. Monday MorningAfternoonAnytime Tuesday MorningAfternoonAnytime Wednesday MorningAfternoonAnytime Thursday MorningAfternoonAnytime Friday MorningAfternoonAnytime A %PPD for a newly allowed condition in this claim I understand if an exam is scheduled, I am required to attend.Please list newly allowed condition(s) here: If there are specific dates you cannot attend an examination in the next six weeks, please list them below. If you are only available before/after a specific time of day (morning or afternoon), please note that time (e.g., only after 3 p.m.). Check here if you need an interpreter to attend the exam. Injured worker signature I certify the information on this form is true and correct. I understand that any person who knowingly makes a false statement, misrepresentation, concealment of fact or any other act of fraud to obtain benefits/compensation as provided by BWC or self - insu ring employers, or who knowingly accepts compensation to which that person is not entitled, is subject to criminal prosecution and may, under appropriate criminal provisions, be punished by a fine or imprisonment or both. I certify all the information lis ted above is current as of the time of the filing of this application. Signature of injured worker/injured worker representative Date number Email Mail American LegalNet, Inc. www.FormsWorkFlow.com Application for Determination or Increase of Percentage of Permanent Partial Disability (C - 92) BWC - 1214 (C - 92 a n d C - 92 - A combined) (Rev. June 20 , 2018 ) C - 92 Injured worker representative name Representative ID number I hereby authorize and direct BWC to mail directly to my attorney the compensation payment in the above numbered claim any accrued monetary award generated by this application. This authorization does not give my attorney the authority to cash or endorse a check on my behalf. This authorization shall not continue in effect after BWC has paid said award(s) on the original application noted above unle ss there is a subsequent hearing, appeal or reconsideration after payment was made. This authorization is not v alid if it is filed beyond 18 months from the date of my signature. Signature of injured worker Date American LegalNet, Inc. www.FormsWorkFlow.com