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Application For Compensation For Permanent Total Disability IC-2 - Ohio
| Application For Compensation For Permanent Total Disability Form. This is a Ohio form and can be used in Industrial Commission Workers Comp . |
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APPLICATION FOR COMPENSATION FOR PERMANENT TOTAL DISABILITY *Please type or print clearly and answer ALL questions to the best of your ability. *To ensure prompt processing, this application should be filed directly with: The Industrial Commission of Ohio Medical Services 30 W. Spring St. 10th floor Columbus, Ohio 43215-2233 Injured Worker's Name Social Security Number Date of Birth Address Telephone Number ( City State ) Zip Code List your worker's compensation claims below: Claim Number__________________ Date of Injury___________ Employer_________________ Claim Number__________________ Date of Injury___________ Employer_________________ Claim Number__________________ Date of Injury___________ Employer_________________ Claim Number__________________ Date of Injury___________ Employer_________________ Medical examinations will be conducted for conditions allowed in active claims. OTHER DISABILITY BENEFITS Have you ever filed for Social Security Disability benefits? yes no If you are now, or have ever, received Social Security Disability payments, complete the following section. *This does not apply to Social Security Retirement* STARTING DATE TERMINATION DATE AND REASON FOR TERMINATION RATE PER MONTH Do you receive disability benefits other than Social Security? (i.e., VA, Fireman & Police Officer Disability, etc.) yes no EDUCATION What is the highest grade of school you completed? _______________ When? ______________________ Where? __________________________________________________ Did you graduate from high school? yes no If no, did you receive a certificate for passing the General Educational Development test (GED)? yes no Why did you end your schooling? ___________________________________________________________ Have you gone to trade or vocational school or had any type of special training? yes no Notice: IC USE ONLY IC-2 Page 1 Upon receipt of this application, forward immediately to: The Industrial Commission of Ohio, Medical Services, at the address indicated above. OIC 3012 (rev 10/11) American LegalNet, Inc. www.FormsWorkFlow.com If yes, what type of trade school or special training have you received and when? _______________________________________________________________________________________ _______________________________________________________________________________________ How has this schooling or training been used in any of the work you have done? ___________________________________________________________________________________________ Can you read? Can you write? Can you do basic math? yes yes yes not well not well not well no no no MEDICAL HISTORY Doctor's Name______________________________Address Date first seen______________________________ Date last seen Reason Doctor's Name______________________________ Address Date first seen______________________________ Date last seen Reason Doctor's Name______________________________ Address Date first seen______________________________ Date last seen Reason List all operations and surgical procedures you have undergone, beginning with the most recent. Date______________________ Name of surgical procedure Date______________________ Name of surgical procedure ____________________________________________ Date______________________ Name of surgical procedure ____________________________________________ Date______________________ Name of surgical procedure ____________________________________________ Date______________________ Name of surgical procedure ____________________________________________ Do you use a cane, brace, TENS unit, traction device, oxygen machine, or any other appliance or device on a regular basis? yes no If yes, please specify. What other medical conditions prevent you from working? ____________________________________________ REHABILITATION HISTORY Have you ever participated in rehabilitation services? yes no Please explain._________________ __________________________________________________________________________________________ If you have not sought or participated in rehabilitation services, are you interested in rehabilitation services offered by the employer or the Bureau of Workers' Compensation and do you desire to undergo rehabilitation evaluation? yes no IC-2 Page 2 OIC 3012 (rev 10/11) American LegalNet, Inc. www.FormsWorkFlow.com DAILY ACTIVITIES Has your treating physician told you to cut back or limit your activities in any way? Yes No If yes, give the name of the doctor and tell below what he told you about cutting back or limiting your activities. Can you drive a car? Yes No Describe your daily activities in the following areas and how much you do of each and how often. Housekeeping Chores: (meal preparation, laundry, home repairs, etc.) Recreational Activities and Hobbies: (bowling, hunting, etc.) Describe other limitations or changes in your life style, if any, resulting from the allowed conditions in your claim. WORK HISTORY Part 1 INFORMATION ABOUT YOUR WORK HISTORY List all the jobs you have had. Start with your most recent job and work backwards to the first job you ever held. List SELF-EMPLOYMENT as you would any other job. Job Title (Be sure to begin with your most recent job.) Type of Business or Industry (Example: auto, insurance, construction, etc.) Dates Worked (Month and Year) From To Days Per Week Specify Rate of Pay (per hour, day, week, month or year) 1 2 3 4 5 6 7 8 IC-2 Page 3 OIC 3012 (rev 10/11) American LegalNet, Inc. www.FormsWorkFlow.com When was the last date you worked anywhere? ______________________________ Do you have military experience? positions held and description of duties. ______________________________________________________________________________________________ ______________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ yes no If yes, provide dates of service, Job Title No. 1 (from Part 1) ______________________________ A Describe your basic duties - what you did and how you did it. Please provide as much detail as possible. 1. Your basic duties: ______________________________________________________________________________________________ ______________________________________________________________________________________________ _____________________________________________________________________________________________
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