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Form Sawc-125 - General Instructions For Completing The Claim Reopening Application For Temporary Total Disability/wage Replacement Benefits Page 3

1. Employer’s Name, Address and Telephone Number (include

2. Do you disagree with any of the information contained in

area code)

Section I or III of this form?

___Yes___No

If yes, explain the information with which you disagree. Be

specific.

3. The claimant began missing work again on:

4. The employer waives the 10 day notice period and does not

object to Zurich’s immediate ruling on the claimant’s petition.

___Yes___No

5. Employer’s Signature

Title

Date

2. Physician’s FEIN or Vendor Number

Physician’s Name, Address and Telephone Number

3. Are you the previously authorized attending physician in this

4. Date of examination upon which these findings are based

claim?

___ Yes ___ No

5. List the current diagnosis (include specific ICD10-CM codes and description), and indicate if you are requesting that a new body part

be added.

6. List the claimant’s complaints as it relates to the compensable injury or occupational disease.

7. Has there been an aggravation or progression of the claimant’s disability since being released to resume employment or being

certified as having

reached maximum degree of medical improvement? ___Yes___No

If yes, list the physical findings that relate to the aggravation/progression of the injury or occupational disease.

Please indicate the date and location for any diagnostic testing that was administered, as well as the results.

8. List any requests for authorizations as it relates to the compensable injury or occupational disease. Please attach any office notes or

medical reports.

9. Can the claimant now perform regular duty? ___Yes ___No

If no, under what restrictions could the claimant work?

If yes, list any work restrictions on the patient’s functional abilities.

10. Please list exact periods of Temporary Total Disability:

From

11. Physician’s Signature

Date

SAWC-125

06/15

Form Sawc-125 - General Instructions For Completing The Claim Reopening Application For Temporary Total Disability/wage Replacement Benefits Page 3