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Form Erd - 987 - Application Form For Certification By The Subsequent Injury Fund Form - State Of Montana, Department Of Labor And Industry

RIGHTS

The Subsequent Injury Fund is intended as an incentive to employers to hire persons having a disability which is a barrier to

employment. This program may NOT be used as a means of discrimination against you. Various laws have been enacted to prevent

discrimination on the basis of a person’s disability.

The Workers’ Compensation Act provides that an injured worker who has been medically released and is capable of returning

to work within two (2) years of injury must be given hiring preference over other applicants for a comparable position that becomes

vacant if the position is consistent with the workers’ physical condition and vocational abilities; and

The Human Rights Act prohibits discrimination against handicapped individuals if they are otherwise qualified to perform

duties of the job with reasonable accommodations by the employer.

The Americans Disabilities Act prohibits employers of 15 or more employees from discriminating against qualified workers or

job applicants on the basis of their disability.

If you feel an employer is discriminating against you or using the Subsequent Injury Fund to discriminate against you, call the

Human Rights Commission at 1-800-542-0807.

RESPONSIBILITIES AND CONSENT

I understand and agree I am applying for certification as a person having a disability. I believe I have a medically certifiable

permanent impairment, which is a substantial obstacle to obtaining employment. SIGNING THIS APPLICATION FORM FOR

CERTIFICATION IS MY AUTHORIZATION FOR RELEASE OF HEALTH CARE INFORMATION, MEDICAL

RECORDS, WORKERS’ COMPENSATION, REHABILITATION RECORDS AND RECORDDS OF THE SOCIAL

SECURITY ADMINISTRATION TO THE SUBSEQUENT INJURY FUND, EMPLOYMENT RELATIONS DIVISION.

_____________________________________________________________________

_________________________

SIGNATURE OF APPLICANT

DATE

Name and Address of Referring Agent

_________________________________________

Telephone:_________________________

ERD – 985 (REV. 07/05/2000)

Form Erd - 987 - Application Form For Certification By The Subsequent Injury Fund Form - State Of Montana, Department Of Labor And Industry