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Form Sawc-125 - General Instructions For Completing The Claim Reopening Application For Temporary Total Disability/wage Replacement Benefits

Send Completed Form To:

STATE OF WEST VIRGINIA

Zurich Insurance

STATE AGENCY

PO Box 66941

WORKERS’ COMPENSATION PROGRAM

Chicago, IL 60666-0941

FAX: 847-240-8172

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.

SAWC-125

06/15

Form Sawc-125 - General Instructions For Completing The Claim Reopening Application For Temporary Total Disability/wage Replacement Benefits