West Virginia > Workers Comp
Return To Work Notice BI-309 - West Virginia
| Return To Work Notice Form. This is a West Virginia form and can be used in Workers Comp . |
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BI-309 01/06 Return to Work Notice Claimant's Name: G IVE C LA IM AN T' S C OM PL ETE NA ME AN D ADD RESS. PLEA SE T YPE OR PR INT U SING INK PEN TO INSURE CL AR IT Y. Return completed form to: BrickStreet Mutual Insurance P.O. Box 3151 Charleston, WV 25332-3151 Claimant's Address: City, State, Zip: Claim Number: Social Security Number: Date of Injury: The above named employee began MISSING work on: The above names employee RETURNED to work on: Signed: Title Employer: Date: EMPLOYER: DO NOT WRITE BELOW T HIS LINE. Dear Claimant: BrickStreet Mutual Insurance has received information from your employer that you returned to work on the date indicated on the Return to Work form (see above). If you have received or receive any temporary total disability benefits in the above-referenced claim for periods subsequent to your return to work, without medical substantiation and supporting substantiation from your employer showing your temporary total disability during such periods, such payments are overpayments for which you are not jurisdictionally entitled and for which you are required to reimburse BrickStreet. Your claim is hereby closed on a temporary total disability basis. However, provided that your claim is ultimately held compensable, if within five years of the receipt of your last payment on your temporary total disability or permanent total disability award, you again become temporarily and totally disabled as a result of your compensable injury, you may petition BrickStreet Insurance to reopen your claim on a temporary total disability basis. Your written petition must be accompanied by a medical report from your attending physician substantiating a progression or aggravation in your condition, or some other fact or facts which were not theretofore considered by BrickStreet. You should also provide a report from your employer confirming the date you began missing work and your date of return to work, if so indicated. If you object to BrickStreet's action in closing your claim on a temporary total disability basis, a written protest must be filed within 30 days from receipt of this letter. Type Line 3 Received Page Action To From Line 4 Soc. Sec. No. D.O.I. Line 1 Line 2 American LegalNet, Inc. www.USCourtForms.com
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