Form 687 - Report Of Disability - Central States Of Omaha (Cso) Page 2
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1
2PART III
EMPLOYER’S STATEMENT
SIDE 2
EMPLOYEE NAME
When did employee fi rst cease work entirely?
On what date did employee resume any part of his/her work, supervisory or other-
Please attach:
copy of employee’s job description, or
wise?
Date: ________________________________________
a statement which details the employee’s job duties
Was injury or sickness covered under Workmen’s Compensation?
Did employee work
full or
part time at the onset of disability?
No
Yes
Hire Date ________________________
If yes, when was injury or sickness? _______________________ , _______
Name and address of Workmen’s Compensation carrier:
If part time, how many hours a week _______________________
__________________________________________________________
Does your company allow light duty?
Yes
No
__________________________________________________________
Date ___________________________________, ______
Signed _______________________________________________________________________________
Company Name and Authorized Signature
(Phone)
____________________________________________________________________________________
(Street and No.)
(City or Town)
(State)
(Zip)
SELF-EMPLOYED STATEMENT
Name and Address of Business
Website Address / E-mail Address
Business Phone Number
Type of Business
What date did you start your business?
How many hours did you work prior to your total disability
Have you returned to your regular,
If yes, on what date?
If no, is the business still operational?
Yes
No
full-time job?
Yes
No
Is so, in what capacity?
Have you returned to work part-time or with restrictions?
If yes, how many hours per week?
What restrictions?
Yes
No
Date ___________________________________, ______
Your Signature _______________________________________________________________________
PART IV
ATTENDING PHYSICIAN’S STATEMENT
1. Patient’s Name
Age
2. Diagnosis (if surgery, describe)
3. Date of Onset
When did patient fi rst consult you for this condition?
4. Give all dates of treatment
5. If hospitalized, give name and address of hospital:
Dates of confi nement:
6. Has any other Physician seen patient for this condition?
Yes
No
If yes, please provide:
Physician’s Name:
Address:
Phone No.:
__________________________________________________________
________________________________________________________________
__________________________________________________________
________________________________________________________________
7. Please indicate the patients next scheduled apointment date along with the name and address of the Physician the patient will be seeing:
Appointment Date: ________________________________ Physician’s Name and Address:_____________________________________________________
8. Patient is / was:
Totally Disabled? (Unable to work their own occupation)
Partially Disabled (Light duty own occupation)
From ___________________through _________________
From ___________________through _________________
If Partially Disabled, please list restrictions:
Estimated future disability
Weeks _________
Months _______
Date you anticipate patient returning to work __________________________________
9. Have you treated this patient for any other conditions?
Yes
No
If yes, please give diagnosis and treatment dates.
Diagnosis:
Treatment Dates:
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Date _____________________________ , _________
Phone __________________________________
Fax __________________________________
Attending Physician’s Signature and Typed Name __________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
(Address)
(City or Town)
(State)
(Zip Code)
Form 687 13th Rev.
8-10
This form cannot be laser printed or reproduced without prior approval from CSO.
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