Form Sawc-125 - General Instructions For Completing The Claim Reopening Application For Temporary Total Disability/wage Replacement Benefits Page 2

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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
CLAIM REOPENING APPLICATION FOR
TEMPORARY TOTAL DISABILITY / WAGE REPLACEMENT BENEFITS
PLEASE PRINT OR TYPE
Step 1 Claimant – Complete Section I and take this form to your doctor.
Step 2 Physician – Complete Section III and return this form to the claimant for delivery to employer at time of injury, or send to Zurich
Insurance at PO Box 66941, Chicago, IL 60666-0941.
Step 3 (Optional) Claimant – Take this form to the employer for whom you worked at the time of your injury to complete Section II.
Step 4 Claimant – Send completed form to Zurich Insurance at PO Box 66941, Chicago, IL 60666-0941. It is your responsibility to
ensure Zurich Insurance receives the completed form.
Claimant’s Name (First, Middle, Last)
Social Security Number – Last four
1.
2.
3.
Date of Injury
digits only.
4.
Mailing Address (Street or PO Box, City,
5.
Telephone Number (include area
6.
Claim Number
State, Zip)
code)
7.
Please check the appropriate box:
I am requesting additional Temporary Total Disability (TTD)/Wage Replacement benefits due to:
___ Aggravation and/or progression of condition or disability resulting from the compensable injury or occupational disease.
___ Fact or factors pertaining to the disability or condition not previously considered by Zurich Insurance in previous findings.
8.
Have you suffered any other illness and/or injuries since the injury upon which this claim is based? ___yes ___no
If yes, specify the nature of the illness and/or injuries, the dates of the illnesses and/or injuries. Please list the names and address of
the physicians who treated you.
Have you filed any other workers’ compensation claim in West Virginia or any other state? ___Yes ___No
9.
If yes, list all claim numbers and/or dates of injuries or occupational disease.
10.
Have you drawn either unemployment or other wage replacement benefits since you were last paid TTD benefits in this claim?
___Yes ___ No
If yes, please state the source (s) and for what time periods you received other benefits.
11. Have you earned wages since you were last paid TTD benefits in this claim?
___Yes ___No
If yes, please list who you worked for and provide time periods of earned wages.
Have you retired? ___Yes ___No
If yes, please list employer’s name and any benefits (i.e. Social Security, pension, etc.) you are
12.
receiving.
13. Claimant’s Signature
Date
SAWC-125
06/15

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