BI-VRA 01/06 Return completed form to: Vocational Rehabilitation Agreement Claimant Name: Claim Number: Address: BrickStreet Mutual Insurance P.O. Box 3151 Charleston, WV 25332-3151 Social Security Number: Date of Injury: STATEMENT OF INTEREST IN VOCATIONAL REHABILITATION SERVICES As a claimant, I wish to be considered for rehabilitation services. I will cooperate fully with the assigned Qualified Rehabilitation Professional (QRP) in the rehabilitation plan development and will participate fully in the prescribed rehabilitation services. I understand that these services may necessitate contact be made with my physician, employer, attorney and/or other professionals. I agree that the QRP may obtain medical, hospital and other reports from physicians and other health professionals providing treatment or evaluation due to the compensable injury. This information is to be used for the evaluation of my vocational rehabilitation needs as requested by BrickStreet Insurance. I understand that I am entitled to a private examination with any medical provider outside of the presence of the QRP. I understand that if I choose to discontinue participation, I will notify the QRP and/or my claims adjuster at BrickStreet Insurance as soon as possible. CLAIMANT CERTIFICATION By signing below, I certify that I have read and understand the statements above. I will fully cooperate in the development of my rehabilitation plan and participate in the recommended services. I understand the statutory limits on rehabilitation benefits outlines in WV Code 23-4-9 and that all rehabilitation expenditures are applied to the $20,000 limit. Claimant Signature: Date: STATEMENT DECLINING VOCATIONAL REHABILITATION SERVICES By signing below, I certify that I have read and understand the statements above and I wish to decline vocational rehabilitation services at this time. Reason for declining services: Claimant Signature: Date: QRP Signature: Date: BrickStreet Mutual Insurance P.O. Box 3151 Charleston, WV 25332-3151 American LegalNet, Inc. www.USCourtForms.com