Application Form For Second Injury - Indiana Workers Compensation Board
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Indiana Worker's Compensation Board
PRIVACY NOTICE
Application for Second Injury Fund Benefits
*This agency is requesting disclosure
of your Social Security number in
State Form 51247 (2-03)
accordance with IC 22-3-4-13. This
disclosure is not mandatory and you
Instructions: This form must be submitted in duplicate to: Indiana Workers Compensation Board
will not be penalized for refusing.
402 W. Washington, RM W196, Indianapolis, IN 46204-2753
CLAIMANT INFORMATION
Social Security Number *
Date of Birth
Last Name
First
Middle
Address
City
Phone
State
Zip
(
)
INJURY INFORMATION
Date of Injury
Disputed Cause #
Date of Award
Type of Injury/Illness
Part of Body
Briefly describe the injury in your own words
Check here if you have received any second injury fund payments for this accident.
CLAIMANT'S AFFIDAVIT
As the injured party requesting benefits of the second injury fund administered by the Indiana Worker's Compensation fund, I do hereby
solemnly swear and affirm that the information given in this application is a true and accurate representation of the information regarding
my work-related injury, as witnessed on this ___________day of ___________________, two thousand and _____________________.
Notary Seal
Notary Signature
Applicant Signature
Notary Printed Name
Applicant Printed Name
Notary Commission Expiration Date
Date Prepared
APPLICATION CHECKLIST
In order to proceed in processing this application, The Board must receive from you the following items (Please Check):
This completed application is signed and notarized
Form submitted in duplicate
A current copy of the applicant's medical report.
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