Second Injury Fund Verified Petition Page 2
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3Brief Description of Treatment Received For Last Compensable Injury or Disease:
Current Medical Conditions: (List physical and/or psychiatric conditions which have been caused, aggravated or accelerated by the last compensable accident or exposure or dates
of onset:
If you have initiated an action at law against a third party for all or any portion of the injury or disease you sustained as a result of your last compensable injury or disease, please
provide the name and address of such third party, the status of your action, and, if concluded, the gross settlement amount of such action.
Provide below your current monthly income from the following sources:
Social Security Retirement:
$
If receiving Social Security retirement benefits, provide the date of your entitlement:
Social Security Disability:
$
If receiving Social Security Disability benefits, provide the date of your entitlement:
Auxiliary Social Security:
$
If receiving Auxiliary Social Security, provide the date of your entitlement:
Black Lung Benefits:
$
If receiving Black Lung benefits, provide the date of your entitlement:
Retirement Pension Benefits:
$
If receiving Retirement Pension, provide the date you began receiving same:
Disability Retirement Benefits:
$
If receiving Disability Retirement Benefits, provide the date you began receiving same:
Veterans Administration Benefits:
$
If receiving Veterans Administration Benefits, provide the date you began receiving same:
Temporary Disability Benefits:
$
If receiving Temporary Disability Benefits, provide the dates of such benefits:
Unemployment Benefits:
$
If receiving Unemployment Benefits, provide the dates of such benefits:
Are you currently eligible for benefits from Medicare?
No
Yes If Yes, have you applied for or received Medicare benefits?
Please provide the names and dates of birth of all dependents cited on Page 1.
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