Catastrophic designation: Fill out & sign online

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Click ‘Get Form’ to open the catastrophic designation document in the editor.
Begin by filling out the identifying information section. Enter your Board Claim Number, last name, first name, middle initial, and date of injury.
In section A, provide your occupation, county of injury, birthdate, treating physician's name, specialty, and diagnosis along with any secondary conditions.
For section B, specify the catastrophic rehabilitation supplier you are requesting. Include their name and registration number.
Complete section C by detailing your education level and work history for the past 15 years. Include physical requirements for each job such as lifting weights and hours spent standing or sitting.
Attach a statement from your authorized treating physician regarding your work ability dated within one year of submission.
Fill out the Certificate of Service section to confirm that copies have been sent to all relevant parties.
If applicable, complete the objection notice in section E if there are any objections to be filed.

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See more catastrophic designation versions

We've got more versions of the catastrophic designation form. Select the right catastrophic designation version from the list and start editing it straight away!

Versions	Form popularity	Fillable & printable
2021	4.8 Satisfied (61 Votes)
2018	4.3 Satisfied (79 Votes)
2011	4.3 Satisfied (436 Votes)
2007	4.3 Satisfied (98 Votes)

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How do I create an electronic signature on my catastrophic designation from Google Chrome?

Managing your documentation with DocHub this way is very simple after you have downloaded its extension for Google Chrome. Navigate to the Chrome Web Store and set up DocHub - Sign PDF from Gmail to obtain it. Give our tool access to your Google account, and then open an email containing catastrophic designation as an attachment and point to the file with your cursor - the DocHub extension key will automatically appear there. Click on it to open your form in our editor. Make any required edits, fill out the blanks, and click Sign to create your legally-binding eSignature.

How do you fill out catastrophic designation online?

You can get and modify your catastrophic designation online with the help of DocHub. Its straightforward but feature-rich design allows you to begin effective work right after you register your account. Create your account and add your file, then our user interface will guide you via our stress-free form completion experience.

What is considered a catastrophic injury?

A determination of catastrophic impairment is usually made by your insurance company at the recommendations of medical professionals. Some injuries, such as paraplegia, total loss of vision in both eyes, and complete loss of use of lower or upper extremities, are automatically deemed as catastrophic.