Get Petition For Benefit Determination Form

This guide provides essential instructions for completing the Petition For Benefit Determination Form online. Designed to assist users of all experience levels, it breaks down each section for clarity and thorough understanding.

Follow the steps to complete the Petition For Benefit Determination Form accurately.

1. Press the ‘Get Form’ button to access the Petition For Benefit Determination Form online.
2. Fill in the docket number, state file number, RFA number, date of injury, and your social security number. Ensure these are accurate as they are essential for your claim.
3. Indicate the type of benefits you are applying for by checking all applicable boxes, such as permanent disability benefits or temporary disability benefits.
4. Provide a brief explanation of any disputed issues regarding your claim. Include specific details to clarify your situation.
5. Enter your personal information including your name, address, county of residence, date of birth, phone number, and email address.
6. Input your employer's information, including their name, address, and contact details.
7. If applicable, fill in the details for your attorney and their contact information, ensuring to include the BPR number.
8. Provide details regarding the injury, including the job/occupation at the time of the injury, body parts injured, the location of the accident, and a brief description of how it occurred.
9. Answer the questions about medical care provided, indicating whether a panel of physicians was offered and any permanent impairment ratings received.
10. Select three potential dates and times for mediation if the employee is at maximum medical improvement.
11. Fill out the wage and temporary disability information, including your average weekly wage and whether you have returned to work.
12. Include any relevant documentation to support your petition, such as medical records or notes from your physician.
13. Sign and date the petition, affirming that the information is true to the best of your knowledge.
14. Finally, save your changes and download, print, or share the petition as needed.

Complete your form online today for timely submission and consideration of your petition.