Send Completed Form To:
STATE OF WEST VIRGINIA
PO Box 66941
WORKERS’ COMPENSATION PROGRAM
Chicago, IL 60666-0941
General Instructions for Completing the
Claim Reopening Application
for Temporary Total Disability/Wage Replacement Benefits
Please Read Carefully
A reopening cannot be initiated until the reopening form has been completed in its entirety and
submitted to Zurich Insurance.
SECTION I: EMPLOYEE SECTION
7 – Check first box if there is an aggravation/progression of the condition or disability that resulted
from the compensable injury.
Check the second box if new facts pertaining to the disability or condition were not previously
considered by Zurich Insurance.
Once form is completed, go to line 13 and sign and date.
SECTION II: EMPLOYER SECTION (OPTIONAL)
This section is optional, complete as needed.
This section should be completed by the employer for whom the claimant was working at the time of
the injury or occupational disease covered by this claim. Although this section is optional,
completing it may expedite the consideration of the petition.
As the employer, you can expedite the reopening of the claim by waiving the 10 day notice.
SECTION III: PHYSICIAN SECTION
Complete all information requested in questions 1 – 10.
Physician must sign and date the form on the date of the examination.