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January 6, 2014, Informational Circular 2014-01 To: All Members Second Injury Fund Assessment & Policy Surcharge Factor Second Injury Fund Assessment The Workers Compensation Board of Indiana (Board)

How to fill out second injury fund assessment

1. Start by gathering all necessary information and documentation, such as medical records, accident reports, and any other relevant records related to the first and second injuries.
2. Consult the state's workers' compensation board or the applicable governing body to understand the specific requirements and forms for the second injury fund assessment. Each state may have different guidelines and procedures.
3. Carefully review the application form for the second injury fund assessment and provide accurate and complete information. Pay attention to any specific instructions or sections that need to be filled out.
4. Provide details about the first injury, including the date of the injury, the nature of the injury, and any medical treatment or rehabilitation received. Include any supporting documentation, such as medical reports or bills.
5. Similarly, provide detailed information about the second injury, including the date, nature, and treatment received. Attach any relevant documents to support your claim.
6. Fill out any additional sections or questions on the form, such as details about the employment status at the time of the second injury or any other pertinent information requested.
7. Double-check all the information filled in the form to ensure accuracy and completeness. Any mistakes or missing information can delay the processing of your second injury fund assessment.
8. Submit the completed form and all supporting documentation to the appropriate authority, as specified in the instructions. Keep a copy of the application and supporting documents for your records.

Who needs second injury fund assessment?

1. Employees who have experienced a second injury that resulted in a disability or loss of function and have a pre-existing disability resulting from the first injury may need to undergo a second injury fund assessment.
2. Employers or insurance companies may also need to initiate a second injury fund assessment to determine whether the injured employee qualifies for additional compensation under the second injury fund.
3. Workers' compensation boards or governing bodies responsible for administering the second injury fund also play a crucial role in initiating or overseeing the assessment process to ensure fairness and adherence to the law.

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What is second injury fund assessment?

Second injury fund assessment is a financial obligation imposed on certain employers to support workers who have preexisting disabilities or impairments.

Who is required to file second injury fund assessment?

Employers who hire workers with preexisting disabilities or impairments are usually required to file second injury fund assessment.

How to fill out second injury fund assessment?

Second injury fund assessment forms can usually be filled out online or submitted through mail with information on the number of employees with preexisting disabilities or impairments.

What is the purpose of second injury fund assessment?

The purpose of second injury fund assessment is to ensure that workers with previous disabilities or impairments are protected financially in case of a subsequent work-related injury.

What information must be reported on second injury fund assessment?

Information such as the number of employees with preexisting disabilities, the nature of their disabilities, and the corresponding assessments must be reported on second injury fund assessment forms.