Second Injury Fund Information Review Sheet {WC-380}

Second Injury Fund Information Review Case Name: Wage: Last Day of Work: IF ACCIDENT IF EXPOSURE Date of Accident: Last Exposure on: Claim Petition Number(s): Rate: DOB: Last Day on Payroll (if different): Injuries to: Injuries to: Amount of Temporary Disability Paid: $ Additional Temporary Disability Claimed: $ Medicals To Be Paid: From: From: To: To: Check All That Apply: Voluntary Tender, (if checked) Amount: $ Medicare Entitled Conditional Payment Info. Requested SSD Recipient (if checked): 1. Date of Entitlement: 2. 80% ACE $ 3. Initial Entitlement $ Includes Auxiliaries: yes no Third Party Action (if checked): Recovery: $ Public Pension (if checked): Type of Pension: List Treating Doctors and Hospitals (Including Pre-Existing): Pre-existing Disabilities and Compensation Awards: Petitioner Evaluating Doctors and Estimates: Respondent Evaluating Doctors and Estimates: WC-380 (6-08) American LegalNet, Inc. www.FormsWorkflow.com