BI-115 01/06 Application for Permanent Total Disability Benefits Return completed form to: BrickStreet Mutual Insurance P.O. Box 791 Charleston, WV 25322-0791 PLEASE REVIEW THE INSTRUCTIONS AND COMPLETE ALL FIELDS BELOW Please be advised that any person desiring consideration must have:  Been awarded the sum of 50% in prior permanent partial disability awards;  Suffered a single occupational injury or disease which results in a finding by BrickStreet Insurance that a medical impairment of 50% exists; or have  Sustained a 35% statutory disability. All of the information contained in this application for benefits is necessary to properly adjudicate the request. Failure to complete all questions on this application may cause substantial delay and possible rejection for consideration, which may affect your rights to benefits in the future. Any incomplete application will not be accepted and will be returned for complete information. After completion, please forward this application for benefits and any supporting evidence to: BrickStreet Mutual Insurance, Attention: Permanent Total Disability Adjudication Unit P.O. Box 791, Charleston, West Virginia 25322 -0791 1. Personal Information Name Social Security Number Address Date of Birth City, State, Zip Most Recent Date of Injury Phone (include area code) County of Residence PLEASE TYPE OR PRI NT WITH A BLACK OR BLUE BALLPOINT PEN 2. Present Employment Status: Employed Unemployed Self- Employed Off Due to Injury 3. Are you receiving any of the following retirement benefits? Yes No Check any that apply. Social Security Employer-Funded Self-Funded Date Benefits Started: / 4. Are you receiving any of the following disability benefits? Yes No Check any that apply. Social Security Employer-Funded Self-Funded Date Benefits Started: / 5. Are you receiving any income from other sources not listed above? Describe benefit and onset. (Retirement, pension, etc.) Retired / / Benefit: Onset: / / Did you contribute? Yes No Benefit: Onset: / / Did you contribute? Yes No 6. Is there a pending civil action in any of your BrickStreet Insurance claims that has been brought by you or on your behalf? 7. Dependent Information: Please list all dependent information below. Dependent Social Security Number Date of Birth Yes No 8. Please list all BrickStreet Insurance claims and any impairment rating (%) that may have been awarded. Attach additional pages as necessary. Claim Number PPD % Date of Injury If yes, please attach a copy. Relationship Body Part(s) 9. List all disability claims you have filed with other state or federal agencies (include Social Security, veteran’s and workers’ compensation from other states). Attach additional pages as necessary. Please include a copy of the decision granting benefits. 10. List any non work-related conditions for which you have received treatment in the past 10 years. Include the name, address and telephone number of the treating physician, clinics or hospitals that treated you. Attach additional pages as necessary. American LegalNet, Inc. www.FormsWorkflow.com 11. List all prescription medications you are taking and include the name of the prescribing physician. Prescription Medication Prescribing Physician Prescription Medication Prescribing Physician 12. Rehabilitation: List all vocational rehabilitation services you have received because of a work -related condition (job placement, retraining, etc.) Services Received Service Provider Dates of Services 13. Employment History: Please complete your employment history beginning with the most recent and continue in reverse order. Begin Date End Date Employer’s Name / / / / / / / / / / / / / / / / / / / / / / Employer’s Address / / 14. List job titles you have held and any specialized training you received to perform these jobs. Job Title Duties / Training Received Date(s) of Training 15. Educational Background: Please list the names of all schools you have attended. This should include public, private, vocation or colleges and universities. Please include date of attendance and highest degree attained. School Name Location Program Dates Attended Degree / Result 16. Did you receive a GED? Yes 17. Have you served in the military? No Yes If yes, date of completion: No If yes, dates of service: From / / / / 18. If yes, please list the specific military branch, the highest rank attained and any special duties or training received. Branch Highest Rank Attained to / / Training / Duties I certify the statements and answers set forth in this document are true and correct to the best of my knowledge. I am aware the law, generally, Chapters 23 and 61 of the WV Code, and specifically, § 61-3- 24f, provides for severe penalties if I knowingly certify a false report or statement and/or withhold a material fact regarding any information requested by BrickStreet Insurance. I acknowledge the provisions of the aforemenetioned code and the severe penalties for knowingly and with fraudulent intent aiding or abetting anyone in securing or attempting to secure benefits to which he or she is not entitled. Signature Date / / Please contact the Permanent Total Disability Adjudication Unit with any questions you may have regarding the completion of this application at 304.941.1000 or 1.866.45BRICK (866.452.7425.) American LegalNet, Inc. www.FormsWorkflow.com