REQUEST OF CLAIM ALLOWANCE FOR MESOTHELIOMA
REQUEST OF CLAIM ALLOWANCE FOR MESOTHELIOMA
WORK HISTORY QUESTIONNAIRE
To Applicant or Family Member:
To assist us in evaluating your Ohio workers’ Compensation Claim for a diagnosis of mesothelioma, it is important for us to have the following information regarding your employment (all work performed even during high school and military work). Therefore, please complete this form as accurately as possible and forward it to the BWC employee who requested this information. Thank you for your cooperation.
Name (Last, First, Middle Initial): __________________________________________________ BWC Claim Number: ____________________
Social Security Number: ___________________________________ Date of Birth: ___________
Home Mailing Address: _________________________________
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Please list all employers for whom you worked, dates of employment, jobs performed, and exposure to chemicals including asbestos for that particular job during your lifetime including high school and any military service beginning with most recent or your first employer. (Use back page if necessary.)
|Employer Name |Employer Location/City |Dates of Employment |Jobs Performed (Titles) |Known Chemical or |
| |(Address) |(For example, 1956-1959) | |Substance Exposure |
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I attest that the information provided above is honest and accurate to the best of my ability. I understand that any person who obtains compensation from BWC or self-insuring employers by: knowingly misrepresenting or concealing facts, making false statement, or accepting compensation to which he/she is not entitled, is subject to felony criminal prosecution for fraud.
Applicant or Survivor Signature: _____________________________________________ Date: _____________________
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