BI-1 0 West Virginia Workers222 Compensation Employees222 and Physician222s Report of Occupational Injury or Disease For BrickStreet Use Only Claim Number: Team Assigned: SECTION I - EMPLOYEE222S CLAIM INFORMATION 1.Name: LastFirst MI 2.Address:3.Telephone: - - City:State: Zip: 4.Social Security Number: 5.Date of Birth:6.Sex: M F 7.Marital Status: 8.Date of Injury or Last Exposure:Time: a.m. p.m. 9. Time you Began Work on Date of Injury: a.m. p.m. 10.Date you Stopped Working Due to Injury: 11.Have you Retired? Yes No If 223yes,224 what was the date you retired? 12.Employer222s Name:Supervisor222s Name: A ddress: City:State: Zip: Telephone: - - 13.Job Title / Description: 14.Body Parts Injured: 15.Describe How Your Injury Occurred (Specify the cause, what you were doing, and equipment / objects involved): 16.Did Injury Occur on Employer222s Property? Yes No A ddress where Injury Occurred: 17.Please Identify Any Witnesses to Your Injury: I certify that the above is true and correct to the best of my knowledge. I am aware the law provides for severe penalties if I knowingly and with fraudulent intent withhold facts or make false statements in order to obtain or increase benefits to which I am not entitled. By signing this application, I hereby authorize any physician, chiropractor, surgeon, practitioner or other healthcare SECTION II 226 ALL INFORMATION MUST BE COMPLETED BY INITIAL PROVIDER 1.Name of Physician / Hospital:2.FEIN / Social Security Number: 3.Address: City: Zip: Telephone: - - 4.Date of Initial Treatment:5.Date Patient May Return to Work: 6.Have you advised the patient to remain off work 4 or more days? Yes If yes, indicate dates: from to No If no, is the patient capable of Full Duty Modified Duty If the patient is capable of returning to modified duty, specify any limitations/restrictions: 7.Condition is a direct result of: Occupational Injury? Occupational Disease? Non-Occupational Condition? 8.Did this injury aggravate a prior injury / disease? Yes No If yes, explain: 9.Description of injury or occupational disease: 10.Body Part(s) Injured:11.ICD10-CM Diagnosis Code(s) in order of severity: 12.Name of Physician Referred to:13.If the patient was hospitalized, where? 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 provides for severe penalties if I knowingly certify a false report or statement, withhold material fact or statement or knowingly aid or abet anyone attempting to secure benefits to which he or she is not entitled. In signing this form, I acknowledge I have been informed BrickStreet Mutual Insurance P.O. Box 3151 Charleston, WV 25332-3151 American LegalNet, Inc. www.FormsWorkFlow.com General Instructions for Completing the BI-1, 223West Virginia Workers222 Compensation Employees222 and Physician222s Report of Occupational Injury or Disease224 Please Read Carefully BI-1, West Virginia Workers222 Compensation Employees222 and Physician222s Report of Occupational Injury or Disease: To be completed by the claimant and the medical provider. This form should not be used to file occupational pneumoconiosis or hearing loss claims. To the Claimant: Section I of this form must be completed by you. When you have completed this form, make a copy for your records and give a copy to your employer. The initial medical provider is responsible for completing Section II of this form. If you do not receive a decision on your claim within 14 days after submitting the form, contact BrickStreet Insurance. To be eligible for benefits, a claim must be filed with BrickStreet Insurance within six months from and after the injury or death. If you have any questions, you may contact BrickStreet at 1-866-452-7425 or visit our Web site at www.brickstreet.com. To the Initial Medical Provider: Section II of this form must be completed by you. The timely provision of information regarding the claimant222s condition is vital in deciding eligibility for benefits. Each answer should be as specific as possible. You should immediately send a copy of all records, office notes and test results regarding the claimant222s exam to BrickStreet Insurance. Please forward the original completed form to BrickStreet Insurance and provide a copy to the claimant. If you have any questions, you may contact BrickStreet Insurance at 1-866-452-7425 or visit our Web site at www.brickstreet.com. Special Instructions for Section I Question 8 This date is defined as either the date you were injured or the date you were last exposed if you are filing an occupational disease claim. Question 13 Provide your specific job title and describe the duties of the job you are currently working. Question 15 Please provide as much detail as possible and attach additional pages if space is needed. Special Instructions for Section II Questions 1, 2 The group and FEIN are required by BrickStreet for billing purposes. Question 8 Describe in detail what effect, if any, the claimant222s previous health may have on this injury. Please attach additional pages if space is needed and include any appropriate reports. Return completed form to: BrickStreet Mutual Insurance P. O. Box 3151 Charleston, WV 25332-3151 When completing this form, enclose attachments if additional space is needed. American LegalNet, Inc. www.FormsWorkFlow.com