LAB500 EXHIBIT O
Form No. WCSIF-I (9-2015)
APPLICATION FOR THE USE OF THE SECOND INJURY FUND
This application must be filed within 100 weeks from the date of a subsequent
injury to a permanently impaired employee (RSA 281-A:54, V)
_______________________________ _____________________________
Employee Name Date of Injury/Claim #
_______________________________ _____________________________
Employer Name Date of Subsequent Disability
_______________________________ _____________________________
Employer’s Insurance Carrier Appeal of CNA Disability Date
_______________________________ _____________________________
Mailing Address Telephone Number
I, the undersigned, ___________________________________________________________
Name Company
give due notice of the above referenced possible claim against the Second
Injury Fund. I hereby apply for the use of the Fund under the provisions of
Section A:54 of RSA 281 and Section Lab 506.04 of the New Hampshire Code of
Administrative Rules. I acknowledge that all reimbursable benefits payable
under RSA 281 shall be paid direct and without regard to reimbursement. I
further acknowledge that eligibility for reimbursement of such payments from
the Second Injury Fund shall be subject to the proper filing of medical evidence
and proof of employer knowledge as detailed in Section Lab 506.04.
_______________________________ ______________________________
Date Signature
