Get Second Injury Fund Questionnaire And Medical Inquiry

Filling out the Second Injury Fund Questionnaire And Medical Inquiry is an essential process for ensuring that potential employers are aware of any pre-existing conditions or disabilities that a user may have. This guide provides clear, step-by-step instructions to help you complete this form accurately and efficiently online.

Follow the steps to complete the questionnaire online

1. Press the ‘Get Form’ button to access the questionnaire and load it in your digital editor.
2. Begin by entering your personal information. Complete the fields for your name, sex, social security number, birth date, address, city, state, zip code, phone number, marital status, number of children, name of your family physician, and their phone number.
3. Indicate your driver's license number, state of issuance, age, expiration date, and type of license. Make sure to provide accurate details.
4. In the personal medical history section, you will see a list of conditions. Mark an X in the appropriate box under 'Yes' or 'No' for each item that applies to you.
5. Respond to additional inquiries regarding past injuries, surgeries, or medical consultations. Be thorough in your answers, as this information is crucial for the review process.
6. Provide remarks or explanations for any 'Yes' responses in the designated area. This may help clarify your medical history.
7. Finally, read the certification statement carefully. Your signature and date confirm that the information provided is true and complete. Additionally, signatures from a witness and a manager are required.
8. Once you have completed the questionnaire, ensure that you save your changes. You may choose to download, print, or share the completed form as necessary.

Complete your Second Injury Fund Questionnaire And Medical Inquiry online to ensure your eligibility for employer reimbursements.