Form C-84 Bwc-1205 - Request For Temporary Total Compensation - 2012
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1
2Request for Temporary Total
Compensation
Injured worker demographics
Name
Claim number
Date of injury
Address
City
State
Nine-digit ZIP code
1
Email address (optional)
Home phone number
Cell phone number
—
—
—
—
Disability information
•
Is this application requesting a new period of temporary total compensation or an extension?
New
Extension
n
n
/
/
•
If this is a new period, what was the last date worked due to the current period of work-related disability? _____________________
2
•
List all providers currently treating you for this work-related disability claim. ________________________________________________________
________________________________________________________________________________________________________________________________
Employment information
What was your occupation at the time of the injury/disease? _________________________________________________________________________
• Do you have a job to return to?
Yes
No
I don’t know
n
n
n
o If yes, who is your employer? __________________________________________________________________________________________________
o If yes, does your employer offer modified (light-duty) work?
Yes
No
I don’t know
n
n
n
o If yes, do you feel capable of performing any of your job duties at this time?
Yes
No
n
n
If yes, what duties? ___________________________________________________________________________________________________________
Working includes full or part-time, self-employment, income-producing hobbies, commission work, or unpaid activities that are not minimal
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and directly earn income for someone else.
• Are you currently working in any capacity (as defined above)?
Yes
No
n
n
o If yes, who is your employer? __________________________________________________________________________________________________
• Have you previously worked in any capacity (as defined above) during this requested period of disability?
Yes
No
n
n
o If yes, who is your employer? __________________________________________________________________________________________________
/
/
o If no, when was the last date you worked anywhere? _____________________ Reason for leaving ____________________________________
• What do you feel is preventing you from returning to work at this time? Please describe physical, employment and personal barriers.
________________________________________________________________________________________________________________________________
Vocational rehabilitation information
Vocational rehabilitation is an individualized and voluntary program for an eligible injured worker who needs assistance in safely returning
to work or in retaining employment. This program can be tailored around an injured worker’s restrictions and may provide job-seeking skills
or necessary retraining.
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•
If appropriate, would you consider participating in vocational rehabilitation?
Yes
No If no, why not? ____________________________
n
n
________________________________________________________________________________________________________________________________
Benefits/earnings received or requested during the period of disability
Type of benefit
Receiving
Beginning date of benefit
Unemployment
Yes
No
n
n
If yes, from which state are you receiving benefits? _____________________________________
Yes
No
Social Security retirement
n
n
Public assistance
Yes
No
n
n
If yes, include case number: ____________________________________________________________
Sick leave
Yes
No
n
n
If yes, name of company paying the benefit: _____________________________________________
5
Wage/salary continuation
Yes
No
n
n
If yes, name of company paying the benefit: ____________________________________________
Disability
Yes
No
n
n
If yes, name of company paying the benefit: ____________________________________________
Earnings
(to include full or part time, self employment, income-producing hobbies or commission work)
Yes
No
n
n
If yes, name of employer and job duties. _______________________________________________
Injured worker signature
I understand I am not permitted to work while receiving temporary total compensation. I have answered the foregoing questions truthfully
and completely. I am aware that any person who knowingly makes a false statement, misrepresentation, concealment of fact or any other
act of fraud to obtain compensation as provided by BWC or who knowingly accepts compensation to which that person is not entitled is
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subject to felony criminal prosecution and may, under appropriate criminal provisions, be punished by a fine, imprisonment or both.
Signature
Date
C-84
BWC-1205 (Rev. 6/26/2012)
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