Send Co
ompleted Fo
orm To:
Zurich Insuran
nce
PO
O Box 968053
Schaum
mburg, IL 60
0196-8053
STATE OF
O WEST VIRGINIA
STATE AGENCY
A
WORKERS’ COMPE
ENSATION PROGRAM
West Virginia
V
Workers’
W
C
Compensaation
Em
mployee’s and Physician’s Reeport of Occcupation
nal Injury or Diseasee
AN EMPLOYE
EE OF THE ST
TATE OF WES
ST VIRGINIA OR
O ITS POLIT
TICAL SUBDIV
VISIONS MUST
T ALSO COMP
PLETE AN
ELECTION
N OF OPTION
N FORM
S
Section I
EM
MPLOYEE CL
LAIM INFOR
RMATION
PLE
EASE PRINT O
OR TYPE
IInsurer: West Virginia Department of Education
Third P
Party Administrrator:
N
Name: (Last):
A
Address:
C
City:
D
Date of birth:
D
Date of Injury or
o
L
Last Exposure:
(First):
Telephoone Number:
State:
Zip:
Sex:
M
Social S
Security Numbber:
F
Marital Status:
Timee:
a.m.
D
Date you stopped working du
ue to injury:
(M.I..):
p.m
m.
Time yoou Began Worrk on Date of Innjury:
p.m.
a.m.
Have yoou retired?
Yes
No
If “Yes””, what was thhe date you retirred?
E
Employer’s Naame:
Superviisor’s Name:
A
Address:
C
City:
Statee:
Zip:
Telephone: (
)
JJob Title/Descrription:
B
Body Part(s) In
njured:
D
Describe how your
y
injury occcurred (Specify
y the cause, wh
hat you were dooing and equippment/objects innvolved):
Adddress where injjury occurred:
D
Did injury occu
ur on employerr’s property?
Yes
No
P
Please Identify any Witnessess to Your Injurry:
I certify that the above is true and
d correct to the best
b of my know
wledge. I am awaare the law provvides for severe ppenalties if I knoowingly and
w
with fraudulent in
ntent withhold facts
f
or make false statements in order to obtain or increase beneefits to which I aam not entitled. By signing
thhis application, I hereby authorizze any physician
n, chiropractor, surgeon,
s
practitiooner or other healthcare provideer, any hospital, iincluding
V
Veteran’s Admin
nistration or governmental hospital and medical service organizaation, any insuraance company, anny law enforcem
ment or
m
military agency, any governmentt benefit agency including the So
ocial Security A
Administration, or any other instittution or organizzation to
release to each otther, any medicaal or other inform
mation, including
g benefits paid oor payable, pertinnent to this injurry or disease, exccept
innformation relattive to the diagno
osis, treatment and/or
a
counseling
g for HIV/AIDS
S, psychological conditions, and//or alcohol or suubstance
aabuse, for which I must give speccific authorizatio
on. A Photostat of this authorizaation shall be as valid as the origginal.
E
Employee’s Sign
nature:
SA
AWC-1
D
Date:
02/12
Section II INITIAL HEALTHCARE PROVIDER CLAIM INFORMATION
PLEASE PRINT OR TYPE
Name of Physician/Hospital:
FEIN/Social Security Number:
Address:
City:
State:
Zip:
Date of Initial Treatment:
Telephone: (
)
Date Patient May Return to Work:
Have you advised the patient to remain off work 4 or more days?
Yes. Indicate dates: from
to
No. If “No”, is the patient capable of:
Full Duty
Modified Duty
If the patient is capable of returning to modified duty, specify any limitations/restrictions:
Condition is a direct result of:
Occupational Injury
Did this injury aggravate a prior injury/disease?
Yes
Occupational Disease
No
Non-Occupational Condition
If “Yes”, explain:
Description of injury or occupational disease:
Body part(s) injured:
ICD9-CM Diagnosis Code(s) in order of severity:
Name of Physician referred to:
If the patient was hospitalized, where?
I certify the statements and answers set forth in this section are true and correct to the best of my knowledge. I am aware the
law provides for severe penalties if I knowingly certify a false report or statement, withold material fact or statement or
knowingly aid or abet anyone attempting to secure benefits to which he or she is not entitled. In signing this form, I
acknowledge I have been informed of my responsibilites under West Virginia’s Workers’ Compensation Law and agree to
abide by such in the administration of services provided thereunder. I understand the submission of false statements or billing
may result in prosecution under state and federal law. I further agree to release any office notes/test results immediately to the
employer or their representative.
Signature:
SAWC-1
Date:
02/12