BI-3 OD 01/06 Employer's Report of Occupational Disease For BrickStreet Use Only Claim Number: Team Assigned: ICD9: P R I O R T O C O MP L E T I N G T H I S F OR M Y OU M U S T RE A D T H E I N S T R U C T I O N S O N T H E B A C K OF T H I S F O R M. I have been informed of my responsibilities under WV Workers' Compensation Law and agree to abide by such in the administration of services provided by BrickStreet Insurance . I am aware the law provides for severe penalties for providing false statements or information. I n i t i a l s o f E m p l o y e r Re p r e s e n t a t i v e : 1. BrickStreet policy number: 2. Industrial c ode: 3. Name of employer as listed with BrickStreet Insurance: Address of employer: City: 4. Employee SSN: 5. Employee name: Job title/description: 6. Address of employee: City: 7. Employee date of birth: / 8. Employee is (c heck all that apply): Owner/part owner Officer 8a. Name and policy number of leasing company: 8b. Name and policy number of client employer: 8c. Date the employee was first assigned to the client employer: 9. If owner, part owner, or officer, are wages included on wage reports? 10. Date employee was first employed by you? 11. Is this employee still employed by you? Yes No / / / / Yes No End date Job title/location / / Yes No / Full-time Volunteer County: State: Sex: Male Female Part-time Leased (if leased employee, complete 8a, 8b, and 8c.) Zip Code: County: State: Date of last exposure: Marital status: Telephone: Zip Code: FEIN or SSN: Phone number: AL L I NF O R MA T IO N MUS T B E CO M PL ET ED If not, indicate last date of employment: 12. Was this employee, while employed by you, exposed to t he hazards of this disease for 60 continuous days? 13. Indicate in the space below all employment with you. Show begin date, end date, location and job title. Begin date End date Job title/location Begin date a. d. b. c. 14. Daily rate of pay on the date of last exposure: $ 15. If part-time employee: Hourly rate: $ 16. Did alleged exposure occur on employer's property? 17. Nature, body part and type of disease: 17a. Nature: 17b. Body part: 17c. Type of disease: 18. Date disease was first diagnosed: If yes, please provide the claim number. 20. Has this work site been tested for employee exposure to air contaminants or noise? If yes, please provide results and dates of testing. Yes / / By whom? Yes Yes e. f. Hours per week (25 or less): No Address where alleged exposure occurred: Phone No No 19. Are you aware of or suspect a previous claim filed for this disease? 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, specifically § 61 -3-24e, 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. 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. S i g n a t u r e : Date: / / BrickStreet Mutual Insurance P.O. Box 3151 Charleston, WV 25332 American LegalNet, Inc. www.USCourtForms.com General instructions for completing the BI-3 OD, "Employer's Report of Occupational Disease" form - Please Read Carefully General Overview: The claim initiation process will involve this application and the appropriate form for the associated disease: Occupational Pneumoconiosis (OP): If the application is for OP benefits, this BI-3OD will be followed by a BI-105, Employee's Report of OP, a BI-205, Physician's Report of OP and an ILO report of the x-ray evidence. Noise-Induced Hearing Loss (H/L): If the application is for H/L benefits, this B-I3OD will be followed by a BI-1HL and a BI-1HLA. Occupational Disease (OD): If the application is for OD benefits, this BI-3OD will be followed by a BI-1 A claim cannot be completed until the BrickStreet has received the required forms and/or required documentation listed above. Please note that W.V. Code 23-4-1 provides that employees of the state and its political subdivisions are ineligible to receive workers' compensation benefits while drawing sick leave benefits at the same time for the same reason. The employee must make his/her choice known in Question 13 on the BI-1, Employee's Report of Injury form in Occupational Disease claims. To the Employer: W.V. Code 23-4-1b requires you to complete and submit the BI-3 form within five days of receipt of notification of the employee's disease, or within five days after the employer has been notified by BrickStreet Insurance that a claim for benefits has been filed on account of an injury. This information is used to assign the liability of the claim. After completing this form, make a copy for your records. If you have any questions, you may contact BrickStreet Insurance at 1-888-4WV-COMP, or 1-866-452-7425. Question Number 1. 4. 5. 7. 8. 8a. 8b. 8c. 13. 14. 17a. 17b/c. 18. 19. 20. Explanation BrickStreet Policy Number indicated on your BrickStreet wage reports and FEIN or Social Security number. Employee's Social Security number. Employee's Name, Marital Status, Job Title/Description, and Telephone number. Employee's Date of Birth and Gender. Leased employees are workers provided by one business to another business. Leasing companies/employers provide workers to other businesses. Client employers accept employees from leasing companies to work a specified period of time. List the specific date the injured worker was first assigned to the Client Employer. Employment history for this employee must be complete for all periods of employment with you. Enter the employee's daily rate of pay on the date of injury. Define injury, i.e., exposure. Part(s) of body affected and how disease occurred, i.e., chest, wrist/ inhalation, repetitive strain. Date disease was diagnosed and the diagnosing physician with contact information. Attach claim numbers if available when mailing copy. Please fax or mail results of the most recent employee exposure sampling and provide dates of previous sampling with results as available. Return completed form to: BrickStreet Insurance Specialty Claims Section P. O. Box 3151 Charleston, WV 25332-03151 When completing this form, enclose attachments if additional space is needed. American LegalNet, Inc. www.USCourtForms.com