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Application For Silicosis Benefits Form - Department Of Labor & Industry, State Of Montana

State of Montana

Department of Labor & Industry

Judy Martz, Governor

Employment Relations Division

WC Regulation Bureau

Administration

BEFORE THE EMPLOYMENT RELATIONS DIVISION

OF THE MONTANA DEPARTMENT OF LABOR AND INDUSTRY

APPLICATION FOR SILICOSIS BENEFITS

Instructions: This form is to be used for persons applying for silicosis benefit payments under the Silicosis Benefit

Program under Section 39-73-105, MCA. In order to be eligible for such payments, a person must: (1) Have

silicosis which resulting in total disability from following continuously any substantial gainful manual occupation;

(2) Not have a salary exceeding $150 per month; (3) Have resided in and been an inhabitant of Montana for at least

ten consecutive years immediately preceding the date of application; and (4) Not be receiving full benefits under the

Montana Occupational Disease Act.

I, __________________________________, HEREBY MAKE APPLICATION FOR SILICOSIS BENEFITS.

Date of Birth: __________________ SSN: __________________.

I HAVE RESIDED IN MONTANA FOR THE PAST TEN (10) CONSECUTIVE YEARS AT THE

FOLLOWING ADDRESSES.

At __________________________________________________ From _______________ To ________________

At___________________________________________________From _______________ To ________________

I WAS EXPOSED TO SILICA DUST DURING EMPLOYMENT AS FOLLOWS:

Employer ______________________________ At _______________________ From __________ To _________

CURRENT EMPLOYER __________________________________ MONTHLY WAGE _________________

OTHER INCOME SOURCES:

Source __________________________________________________________ Amount ____________________

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YOUR SPOUSE: NAME _______________________________________________ BIRTHDATE _________

ADDRESS __________________________________________________________________

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APPLICANTS SIGNATURE ______________________________________ DATE ______________________

Phone (406) 444-6531

FAX (406) 444-3465

P.O. Box 8011

TDD (406) 444-5549

An Equal Opportunity Employer

Helena, MT 59604-8011

Application For Silicosis Benefits Form - Department Of Labor & Industry, State Of Montana