BI-305 01/06 Employers’ Report of Occupational Pneumoconiosis 1. Claimant’s Full Name (First, Middle, Last) 2. Social Security Number Please return completed form to: BrickStreet Mutual Insurance P.O. Box 3151 Charleston, WV 25332-3151 3. Sex Male Female 4. Claim Number (For office use only) 4. Claimant’s Complete Mailing Address (Street or P.O. Box, City, County, State, Zip Code) 6. Employer’s Complete Name 5. Claimant’s Date of Birth (Month/ Day,/Year) 7. Employer’s phone number 8. Employer’s FEIN 9. Employer’s Complete Address (Street or P.O. Box, City, County, State, Zip Code) 11. Date claimant began working (Month/ Day/Year) 13. 12. Is claimant still working for you? Yes No If not, date ceased and reason: While employed by you, was the claimant ever potentially exposed to the hazards of occupational pneumoconiosis for a continuous period of 60 days? Yes No 14. Do you question the claimant’s alleged disability? PLEASE PRINT OR TYPE. 10. Employer’s BrickStreet Policy Number Yes No If yes, please provide complete details (attach additional sheets if necessary). 15. What work was regularly performed by the claimant? 16. Based on the alleged last date of exposure, list the exact location where the claimant last worked Worksite City, Town or Village State 17. Has the claimant filed for any prior Workers’ Compensation benefits while employed by you? Claim Number Impairment % Yes County No If yes, please provide the following: Date of Injury Type of Claim and injured Body Part (s) 18. Claimant’s Employment History - Start with the most recent position (or current position if still employed). List every position the claimant has held with your company as well as previous or other employment of which you are aware. List breaks in employment. Please use a month/day/year format for all dates. (Attach additional sheets if necessary). From To Company Location or Worksite BrickStreet Mutual Insurance P.O. Box 3151 City and State Charleston, WV Department Job Title 25332-3151 American LegalNet, Inc. www.FormsWorkflow.com BI-305 Page 2 19. Please give the dates of any unemployment or layoff. Please use a month/day/year format for all dates. (Attach additional sheets if necessary.) Please print or type. From To Company Reason for Unemployment or Layoff 20. What was the claimant’s daily rate of pay on the date of last employment (Or the date the application was filed if employee is still working)? $ _________________ Daily 21. What were the total earnings of the claimant during the prior four full quarters from the alleged date of exposure: Time Period Gross Wages Most Recent Full Quarter Prior Quarter Prior Quarter Prior Quarter Any person or firm, or the officer of any corporation, who knowingly and willfully makes a false report or statement under oath, affidavit or certification respecting any information required to be provided under this chapter, shall be guilty of a felony and, upon conviction thereof, shall be fined not less than $1,000 nor more than $10,000 or confined in the penitentiary for a definite term of imprisonment of not less than one year nor more than three years or both. Name of Employer or Employer’s Representative Title Phone Number Date Signature of Employer or Employer’s Representative 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 the BrickStreet Mutual Insurance, Occupational Pneumoconiosis Unit at 304. 941.1000 or 1.866.45BRICK (1.866.452.7425). American LegalNet, Inc. www.FormsWorkflow.com