BI-115A 02/06 Application for Permanent Total Disability Addendum Activities Survey Return completed form to: BrickStreet Mutual Insurance Permanent Total Disability Adjudication P.O. Box 791 Charleston, WV 25322-0791 Please review the instructions and complete all fields below. Your application for Permanent Total Disability Benefits has been accepted for review by BrickStreet Insurance. To complete the review process, we need to obtain some additional information. Please answer all applicable questions on the pages below and submit the signed and complete form to: BrickStreet Insurance, Permanent Total Disability Adjudication, P.O. Box 791, Charleston, West Virginia 25322-0791 Following receipt of the requested information, BrickStreet will continue the adjudication process. The adjudication process may consist of additional independent medical evaluations, functional capacity evaluations, vocational rehabilitation assessment and evaluation and any additional testing BrickStreet deems necessary. The completed record will be submitted to the Interdisciplinary Examining Board for recommendations on the granting or denial of permanent total disability benefits. You will be notified in writing of all proceedings in this claim for benefits. Name Claim Number List the last four physicians you have seen, beginning with the most recent. Doctor Address Initial Visit / City / Last Visit / State / Zip Reason Doctor Initial Visit Address / City / Last Visit / State / Zip Reason Doctor Initial Visit MEDICAL HISTORY Address / City / Last Visit / State / Zip Reason Doctor Initial Visit Address City / / Last Visit / State / Zip Reason List all operations and surgical procedures you have undergone, beginning with the most recent. Date Name of Surgical Procedure / Date Date Date / / / / / / / Name of Surgical Procedure Name of Surgical Procedure Name of Surgical Procedure Do you use a cane, brace, TENS unit, traction device, oxygen machine or any other appliance or device on a regular basis? If yes, please specify: Yes No What other medical conditions prevent you from working? American LegalNet, Inc. www.FormsWorkflow.com REHABILITATION HISTORY Have you ever participated in vocational rehabilitation services? Please explain. Yes No If you have not sought or participated in vocational rehabilitation services, are you interested in rehabilitation services offered by the employer or BrickStreet Insurance? Yes No Please describe other limitations or changes in your lifestyle. DAILY ACTIVITIES Has your treating physician told you to cut back or limit your activities in any way? Yes No If yes, give the name of the doctor(s) and explain what he told you about cutting back or limiting your activities. Can you drive a car? Yes No Restrictions or modifications? (Please list) Describe your daily activities in the following areas and list the time spent and frequency of each. Housekeeping: (meal preparation, laundry, home repairs, cleaning, etc.) Recreational activities and hobbies: (bowling, hunting, volunteering with sports, fishing, etc.) List ALL jobs you have had. Start with your most recent and work backward to the first job you ever held. Remember to include any periods of self-employment. Job Title Type of Business or Industry (Construction, mining, etc.) Date Employment Began (MM/YYYY) Date Employment Ended (MM/YYYY) Number of Days Worked in an Average Week Rate of Pay (per hour, day, week, month or year) WORK HISTORY (Begin with your most recent job) American LegalNet, Inc. www.FormsWorkflow.com Additional Information: Please use the space below to describe any other specialized training or skills attained in other work environments. Also include any miscellaneous information you would like to have considered. Please use the format below to describe, in detail, each of the jobs listed in the section above. Please provide as much information as possible. Job Title 1 from above Your basic duties: Machines, tools and equipment you used: Exact operations you performed: Technical knowledge and skills you used: Required reading and writing: Number of people you supervised: Hours in average day spent walking? 1 2 3 4 5 6 7 8 8+ Hours in average day spent standing? 1 2 3 4 5 6 7 8 8+ Hours in average day spent sitting ? 1 2 3 4 5 6 7 8 8+ Hours in average day spent bending? 1 2 3 4 5 6 7 8 8+ Heaviest weight lifted: Lbs. Weight frequently lifted and carried: Lbs. Job Title 2 from above Your basic duties: Machines, tools and equipment you used: Exact operations you performed: Technical knowledge and skills you used: American LegalNet, Inc. www.FormsWorkflow.com Required reading and writing: Number of people you supervised: Hours in average day spent walking? 1 2 3 4 5 6 7 8 8+ Hours in average day spent standing? 1 2 3 4 5 6 7 8 8+ Hours in average day spent sitting ? 1 2 3 4 5 6 7 8 8+ Hours in average day spent bending? 1 2 3 4 5 6 7 8 8+ Heaviest weight lifted: Weight frequently lifted and carried: Lbs. Lbs. Job Title 3 from above Your basic duties: Machines, tools and equipment you used: Exact operations you performed: Technical knowledge and skills you used: Required reading and writing: Number of people you supervised: Hours in average day spent walking? 1 2 3 4 5 6 7 8 8+ Hours in average day spent standing? 1 2 3 4 5 6 7 8 8+ Hours in average day spent sitting ? 1 2 3 4 5 6 7 8 8+ Hours in average day spent bending? 1 2 3 4 5 6 7 8 8+ Heaviest weight lifted: Lbs. Weight frequently lifted and carried: Lbs. Job Title 4 from above Your basic duties: Machines, tools and equipment you used: Exact operations you performed: American LegalNet, Inc. www.FormsWorkflow.com Technical knowledge and skills you used: Required reading and writing: Number of people you supervised: Hours in average day spent walking? 1 2 3 4 5 6 7 8 8+ Hours in average day spent standing? 1 2 3 4 5 6 7 8 8+ Hours in average day spent sitting ? 1 2 3 4 5 6 7 8 8+ Hours in average day spent bending? 1 2 3 4 5 6 7 8 8+ Heaviest weight lifted: Weight frequently lifted and carried: Lbs. Lbs. If additional jobs need to be considered, please attach a separate sheet(s) and follow the above format. I certify the statements and answers set forth in this section 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 aforementioned code and the severe penalties for knowingly with fraudulent intent to aid or abet anyone in securing or attempting to secure benefits to which he or she is not entitled. By signing this application, I authorize BrickStreet to obtain and examine any medical, health, hospital, vocational, employment or other records pertaining to this application and any condition for which I have previously received medical attention as well as all social security retirement and disability records, and, I acknowledged the provisions of WV Code 23- 4-7- providing for release of medical information by a health care provider to my employer or employer representative. Signature Person completing this form: Date Self Other, please list: American LegalNet, Inc. www.FormsWorkflow.com