Untitled. Form mailed to OWCA when the first compensation payment is made and within 10 days of modification/suspension of such payment, a change to SEB, or the payment of a death benefit. 2025

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  1. Click ‘Get Form’ to open it in the editor.
  2. Begin by entering your personal information at the top of the form, including your name, phone number, and Social Security number.
  3. Carefully review each medical condition listed in Section 1. Indicate 'Yes' or 'No' for each condition that applies to you.
  4. If you answered 'Yes' to any conditions, provide detailed explanations on the back of the form as required.
  5. Complete Section 2 by providing your primary care physician's name and address.
  6. In Section 3, indicate if you have ever injured specific body parts and provide details if applicable.
  7. Fill out Sections 4 and 5 regarding any past workers’ compensation claims or physical disabilities.
  8. Finally, sign and date the form at the bottom. Ensure all information is accurate before submission.

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