APPLICATION FOR DETERMINATION OF PERCENTAGE OF PERMANENT PARTIALBetter Workers' CompensationBuilt with you in mind.DISABILITY or INCREASE OF PERMANENT PARTIAL DISABILITYINSTRUCTIONS: Please use a typewriter or ballpoint pen and press firmly to complete this form. You or your representative must sign this form before submission. You must submit three copies and retain one copy for your records. If assistance is needed you may contact your local BWC customer service office.ClaimnumberDetermination of the initial percentage of permanent partial disability (%PPD)Determination in the %PPD for a newly allowed condition in this claim (no new medical required) Application for:COURT COUNTY OFIncrease in the %PPD I believe that the percentage of permanent partial disability has increased over the percentage previously determined. I have attached three copies of the medical report from my doctor to support this application. Medical reports attached are accompanied by evidence of new and changed circumstances.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Calendar No.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)Injured worker nameDate of injurySocial Security NumberState9-digit ZIP CodeCountyCityAddress PART A INJURED WORKER INFORMATIONHome telephone number ()) Work telephone number (. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Telephone number (Employer at the time of injury PART B APPLICATION INFORMATION)THE PEOPLE OF THE STATE OF NEW YORK TOState9-digit ZIP Code CityAddressDescribe the disability which you now consider to be permanent as a result of your injury or occupational disease. How does this injury or occupational disease affect your activities of daily living? (specify parts of the body affected)GREETINGS:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,located at County ofo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomOther workers' compensation claim numbers and the nature of each injury or occupational disease are listed below.CLAIM NUMBERALLOWED CONDITIONALLOWED CONDITIONCLAIM NUMBER1.5.Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.2.6.3.7., one of the Justices of the4.8.Court in Witness, Honorableday of, 20 County,PART C AUTHORIZATIONName of injured worker representative (if represented)REP I.D. number(please print or type)(Attorney must sign above and type name below)Signature of injured worker / injured worker representative (if represented)DateIherebyauthorizetheBWC/employertoforwardanymonetaryawardgeneratedbythisapplicationtotheattorney indicated above for disbursement to me.Attorney(s) forDate Signature of injured workerBWC USE ONLYOffice and P.O. AddressDate mailedEmployer representativeEmployerCopy mailed to:Goldenrod Injured workerPink Employer representativeCanary EmployerWhite Claim fileTelephone No.: Facsimile No.: E-Mail Address:Mobile Tel. No.:BWC-1214 (C-92 and C-92-A combined) (Rev. 5/1/1999) C-92American LegalNet, Inc. www.USCourtForms.com
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