Looking for a Montana Department Of Labor And Industry Forms And Templates? Download it for free!

Form Erd - 987 - Application Form For Certification By The Subsequent Injury Fund Form - State Of Montana, Department Of Labor And Industry Page 2

STATE OF MONTANA

DATE RECEIVED

DEPARTMENT OF LABOR AND INDUSTRY

SUBSEQUENT INJURY FUND

EMPLOYMENT RELATIONS DIVISION

PO BOX 8011

HELENA MT 59604-8011

406-444-7737

APPLICATION FORM

FOR

CERTIFICATION BY THE

SUBSEQUENT INJURY FUND

INSTRUCTIONS

1) PLEASE COMPLETE ALL PARTS OF THIS APPLICATION FORM.

2) SUBMIT A MEDICAL EVIDENCE OF IMPAIRMENT FORM COMPLETED BY YOUR

MEDICAL DOCTOR.

3) SEND BOTH TO THE DEPARTMENT OF LABOR & INDUSTRY AT THE ABOVE ADDRESS

OR TO YOUR REFERRING AGENT.

GENERAL INFORMATION

Name: _______________________________ Birth Date: _________________________________

Address:______________________________ Social Security:___________________________

_____________________________________ Phone: __________________________________

IMPAIRMENT

Part Of Body Affected: _______________________________________________________________

Cause Of Impairment: Congenital _______ Non-Work Related _______ Work Related _______

Are You Receiving Montana Workers’ Compensation Benefits?

Yes _____ No _____

What Restrictions Or Limitations Do You Have Because Of Your Impairment?

In Your Own Words, Explain Why Your Impairment Is Making It Difficult For You To Find Employment:

_________________________________

Attending Physician(s) Name and Address:

____________________________________________________

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 Page 2