BI-105 09/07 Employees’ Report of Occupational Pneumoconiosis 1. Claimant’s Name (First, Middle, Last) 2. Social Security Number 4. Claimant’s Complete Mailing Address (Street, City, County, State, Zip) 6. Date of Birth (Month, Day, Year) 7. Martial Status Single Widowed 9. Date of last exposure to minute particles of dust for a continuous period of 60 days: 3. Sex Male Female 5. Claimant’s Telephone Number (include area code) 8. Do you reside within 25 miles Married of Charleston, WV? Divorced Yes No 10. Have you ceased work? Yes No If yes, when? ( month/date/year) and reason: Return completed form to: BrickStreet Mutual Insurance P.O. Box 3151 Charleston, WV 25322-3151 BrickStreet Use Only DOF ______________________________ DLE ______________________________ County Occ. ______________________________ ______________________________ Agent Claim # ______________________________ ______________________________ G7 B240 C5 J1 500OR 510 PLEASE PRINT OR TYPE 11. Are you currently receiving Federal Black Lung or Workers’ Compensation benefits from any state? Yes No If yes, please provide the following: What type of payments are you receiving? Date payment began (month/day/year): Monthly amount: 12 . List all workers’ compensation claims (WV and other states) – please place impairment rating (%) /award by each claim number. Attach a separate sheet if necessary. Claim Number Impairment % Date of Injury Employer State In Which Injury Type of Claim and Injured Occurred Body Part(s) 13. List all disability claims you have filed with federal agencies (includes social security, veterans’ administrations, etc .) Currently Receiving? (Yes / No) Type of Injury and / or Medical Condition Date Began 14. Do you have a family physician? Physician’s name Yes 15. Other serious illnesses? No 16. Surgery? Yes 17. Accidents? Yes Yes No No No If yes, please provide the following information: Complete Mailing Address (Street, City, State, Zip) Monthly Amount Phone Number (include area code) If yes, please describe illness and indicate date of onset. Include the name of physician and facility where treated. If yes, please describe the surgery and indicate date and name of physician and facility where surgery was performed. If yes, please describe the accident and indicate date of accident and name of physician and facility where treated. 18. Do you have medical reports indicating that you have occupational pneumoconiosis? Yes No If yes, attach a copy of these reports to this application and provide the date of the first diagnosis along with the name, address and phone number of the attending physician who made the diagnosis. Date of Diagnosis Physician Name Complete Mailing Address (Street, City, State, Zip) Phone Number (include area code) 19. Have you had any of the following procedures performed within the last five years? If yes, please provide the following information: Procedure Yes / No Date of Procedure Attending Physician Hospital Name and Address Chest X-Ray Blood Gas Analysis Breathing Studies Tuberculosis Check American LegalNet, Inc. www.FormsWorkflow.com 20. Please list all prescription drugs that you are currently taking and list the physician prescribing each drug. Attach additional sheets if necessary. Prescription Drug Prescribing Physician Prescription Drug Prescribing Physician 21. List all medical conditions for which you have received treatment and the name, address and phone number of the physicians, clinic and/or hospital where treatment or examination were conducted. Attach additional sheets if necessary. Medical Condition Treated By Clinic and / or Hospital 22. List your employment history prior to your date of last exposure. Start with your most recent employer (or current employer if still employed). Union hall employment history printouts should be attached if applicable. Please use a 'month/day/year' format for all dates. Attach additional sheets if necessary. From To Company Location or City and State Type of Industry Job Title Alleged Exposure Worksite Yes No Yes No Yes No 23. How long have you been exposed to the hazards of occupational pneumoconiosis while working in West Virginia? 24. Please list the dates of any unemployment or layoff. Please use a 'month/day/year' format for all dates. From To Company Reason for unemployment or layoff 25. Proof of wages must be provided for the full three years prior to the last day you were allegedly exposed (or current date if still employed in an exposed environment). This proof can be W-2 reports, pay stubs or notarized statements from employers which include their Federal Employer Identification Number (FEIN). If none of this documentation can be obtained, please contact the Social Security Administration and complete a SSA- 7050-F4, Request for Social Security Earning Information. If the employment documentation is not included, your application will not be processed and it will be returned to you for completion. I hereby certify that the statements and answers set forth in this application are true and correct to the best of my knowledge and belief. I am aware the law provides for severe penalties if I knowingly and with fraudulent intent withhold a material fact or make a false statement in order to obtain or increase a benefit to which I am not entitled. By signing this application, I authorize BrickStreet Insurance to obtain and examine any medical, health, vocational, employment or 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 acknowledge the provisions of West Virginia Code 23-4-7 providing the release of medical information by a health care provider to my employer or employer representative. In recognition of the fact that I have filed for West Virginia workers' compensation benefits and in further recognition that access by BrickStreet Insurance to any and all past wage and prior employment information and prior Social Security Retirement and Disability Decisions that are in the possession of the United States Social Security Administration, may be needed in order to obtain a correct ruling on my claim for benefits, I hereby authorize the United States Social Security Administration to release to BrickStreet Insurance, its officers, employees, and agents, any and all wage, employment and medical information and records and any and all past Social Security Retirement and Disability Decisions that the United States Social Security Administration has in its possession regarding me. Note: This release has no expiration date as long as the claim is subject to action by BrickStreet Insurance. Claimant’s Signature If you have an attorney, please provide: Name of claimant’s attorney Date hired Date Attorney’s address Attorney’s phone number (include area code) Attorney’s Signature Return completed form to: BrickStreet Mutual Insurance, P.O. Box 3151, Charleston, West Virginia, 25332-3151. If you have any questions regarding this form, please contact BrickStreet Mutual Insurance at 304.941.1000 or 1.866.45BRICK. American LegalNet, Inc. www.FormsWorkflow.com