Claims Services Division PO Box 50541 Charleston, WV 25305CARRIER'S REQUEST FOR OCCUPATIONAL LUNG CENTER EXAMINATION Only medical information received by the Insurance Commission at least 10 days prior to the examination date will be considered during the examination. CLAIMANT INFORMATION1. Claimant Name: First Name Middle Name or Initial Last Name Generation 2. Claimant Address: Street, City, State, Zip 3. Claimant Phone #: ( ) 4. Claimant SSN: -- Include Area Code 5. Carrier's Claim ID #: 6. Date of Last Exposure with Most Recent Employer:Jurisdiction Claim #: REASON FOR LUNG CENTER EXAMINATION7. Please mark application reason stated below: PRESUMPTIVENON-PRESUMPTIVE New Claim Filing Date of Application: Submit the following information for every claim on file under the claimant's SSN: (1) Non-medical Decision (Required) (2) Employee's Report of Occupational Pneumoconiosis (Required) (3) Physician's Report of Occupational Pneumoconiosis (Required) (4) Physician's International Labor Organization (ILO) Form (Required) (5) Employer's Report of Occupational Pneumoconiosis (When Available) (6) Adjudicated Awards and Compensability Decisions (if applicable)(Final Order) (Required) (7) Previous Occupational Pneumoconiosis Board Findings (Required) Claim Reopening Date of Application:Submit the following information for every claim on file under the claimant's SSN: (1) Request for Reopening (Required) (2) Reopening Decision (Required) (3) Medical Evidence Provided with Reopening Request (Required) (4) Adjudicated Awards and Compensability Decisions(if applicable) (Final Order) (Required) (5) Previous Occupational Pneumoconiosis Board Findings (if applicable) (Required) Requested Due to Outcome of Litigation Submit the following information for every claim on file under the claimant's SSN : (1) Copy of Litigation Decision from Office of Judges, Board of Review or Supreme Court (Required) (2) Adjudicated awards and Compensability Decisions (if applicable) (Final Order) (Required) (3) Previous Occupational Pneumoconiosis Board Findings (if applicable) (Required) Fatal Dependent Benefits Date of Death:Submit the following information for every claim on file under the claimant's SSN: (1) Non-Medical Decision (Required) (2) Application for Dependent Benefits (Required) (3) Death Certificate (Required) (4) Autopsy Report (If Autopsy Performed) (5) Pathology Reports (When Available) (6) Other Medical information - digital x-rays, x-rays, and x-ray reports.240 (Required) (7) Adjudicated awards and Compensability Decisions (if applicable) (Final Order) (Required) (8) Previous Occupational Pneumoconiosis Board Findings (if applicable) (Required) CARRIER AND CONTACT INFORMATION 8. Carrier Name: 9. Contact Person's Name: 10. Contact Person's Phone Number: 11. Contact Person's Email Address: 12. Contact Person's USPS Address: 13. Contact Persons' Signature: 14. Date Signed: RETURN COMPLETED DOCUMENT AND ATTACHMENTS TO ADDRESS AT TOP OF FORM. Incomplete requests will be (Rev. 8/2007) returned to the carrier/responsible administrator. American LegalNet, Inc. www.FormsWorkFlow.com