Fill and Sign the Ohio Workers Compensation 497322544 Form

Single Married Widowed Divorced AM PM Yes No By whom? O.D.      Employer:       Employee:       Beneficiary:       The above named             1. What was deceased's age?       2. From what disease was deceased suffering?       3. What were the symptoms?       4. When did these symptoms first appear?       5. Had deceased previously suffered from this disease?       6. On what day did deceased quit work on account of the disease?       7. Give date of death       Hour of day       8. Name of Attending Physician                                                                                                                                                                                                             Signed             Dated at                   APPLICATION FOR ADJUSTMENT OF CLAIM IN CASE OF DEATH DUE TO OCCUPATIONAL DISEASE INSTRUCTIONS: This form must be filed in duplicate and be accompanied by duplicate copies of the proof relied upon tosupport the claim. (BWC Claim Number) (Employer Address) (Deceased) (Employer or Beneficiary)hereby gives notice to The Bureau of Workers' Compensation that the parties hereto have failed to reach an agreement in regard to compensation, etc., to be paid on account of the death of the above named employee; and hereby makes application to said Bureau for the purpose of determining the amount of compensation, etc., to be paid or furnished to said beneficiary, or beneficiaries, in accordance with the provisions of Section 27 of the Workers' Compensation Act. The reasons for disagreement are as follows: Said applicant, in support of said application, submits the following statement of facts for the consideration of said Bureau: Addres s 9. When did deceased last become a resident of Ohio? 10. Was autopsy performed? ... 11. Give the name and address of the employer or employers for whom deceased worked for ninety days preceding date of death. 12. This application is made on behalf of the above named beneficiary and the following named persons, who were dependent on deceased for support: NAME AGE RELATIONSHIP TO DECEASED WHOLLY OR PARTIALLY 13. The following expenses have been incurred for medical and funeral expenses, etc., in connection with the disability and death of said employee: Nature of Expense Amoun t Nature of Expense Amoun t Medical services Nursing services Hospital services Funera l By signing this application I expressly waive, on behalf of myself and of any person who shall have any interest in this claim, all provisions of law forbidding any physician or other person who has heretofore attended or examined deceased from disclosing any knowledge or information which they thereby acquired. I have read all the statements contained herein and know the same to be true and correct. (Applicant) (Address) thi s day of BWC-4463 (Rev. 2/25/1999) OD-58-22