(Project Use Only - Corr75)
BWCGRANTSTATE FUND TENTATIVE ORDER
PETER M PAUL SR02/02/1995
125 POST RD., APT. L
SPRINGFIELD OH 45503-0000
Injured worker: PETER M PAUL SR
Claim number: 94-350541 Employer’s name: Multi-Care
Injury date: 08/01/1994 Policy number: 1016696
Claim type: Medical Only Employer status: Covered
The current allowed injury(s)/ ICD code(s) in the claim are:
ICDDescriptionBody Location Part of Body
<XXX.XX> <Narrative Description> <Body Location> <Part of Body>
The substantial aggravation injury(s)/ICD code(s) allowed in the claim that are payable are:
ICDDescriptionBody Location Part of Body
<XXX.XX> <Narrative Description> <Body Location> <Part of Body>
The substantial aggravation injury(s)/ICD code(s) allowed in the claim that are not payable are:
ICDDescriptionBody Location Part of Body
<XXX.XX> <Narrative Description> <Body Location> <Part of Body>
The current disallowed injury(s)/ICD code(s) in the claim are:
ICDDescriptionBody Location Part of Body
<XXX.XX> <Narrative Description> <Body Location> <Part of Body>
The Administrator finds that on Date you filed an application for the determination, or subsequent determination (increase) of percentage of permanent partial disability as result of your work-related injury/disease. Pursuant to the provisions of ORC 4123.57, a medical exam or review was conducted on behalf of BWC by DrDr.’s Nameon Exam Date>. A copy of the report resulting from the examination or review is attached.
< Inserts>
…. free form text appears here ….
This award is subject to any applicable family support order.
DELIVER TO:POA
This will only appear if the date of injury is before 8/22/1986
If your claim occurred before August 22, 1986, and you have not previously received permanent partial disability in this claim, you may refuse the award as calculated above and instead elect compensation on the basis of impairment of earning capacity. If you elect such compensation, you must complete and return the enclosed election form within 20 days of the receipt of this order. You will then receive information on calculation of temporary partial compensation. If you do not return the election form within 20 days, you will be determined to have accepted the compensation as calculated above.
The Administrator hereby advises that unless an objection to this tentative order is received in writing within 20 days of receipt of this notice, it shall become final, with no reconsideration, and compensation will be paid as indicated. Objection forms may be obtained from any BWC office. If a timely objection is received, the matter will be set for hearing before an Industrial Commission district hearing officer. Upon referral to a district hearing officer, the employer may obtain a medical examination of the employee, pursuant to rules of the Industrial Commission.
If there are any questions about this claim, contact your claims service specialist at the BWC customer service office listed below.
Grant State Fund Tenative Order Inserts
1. After review of the medical report, the Administrator finds that the evidence warrants the issuance of this TENTATIVE ORDER, finding you entitled to Numberpercent permanent partial disability. This award shall be paid as follows:
%PP EQUALS Weeks FROMDate TO Date AT Rate = Total
2. After review of the medical report, the Administrator finds that the evidence warrants the issuance of this tentative order, finding no percentage of permanent partial disability is recommended; therefore, no award is indicated.
(BWCGRANTSTATE FUND TENTATIVE ORDER)
PETER M PAUL SR02/02/1995
125 POST RD., APT. L
SPRINGFIELD OH 45503-0000
Injured worker: PETER M PAUL SR
Claim number: 94-350541 Employer’s name: Multi-Care
Injury date: 08/01/1994 Policy number: 1016696
Claim type: Medical Only Employer status: Covered
I do not elect to receive benefits for permanent partial disability as calculated on the tentative order. I desire to be compensated on the basis of impairment of earning capacity. I understand that if I have not returned this election form within 20 days, I will be determined to have accepted the compensation calculated on the tentative order.
______
Signature of injured worker
______
Date received
REP 00003 X 03 CLAIMREPTeam Number: 04
MEDICAL ONLY CLAIMSPhone Number: (614) 728-2940
30 W SPRING STFax Number: (614) 752-2927
COLUMBUS OH 43215-2241
CC:
IW REP, EMP, EMP REP