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CURRENT EMPLOYER TYPE OF WORK ADDRESS FROM TO IMPORTANT - FILL IN TOTAL INCOME FOR TWELVE 12 MONTHS BEFORE INJURY REMARKS By THIS INSTRUMENT I MAKE APPLICATION FOR ALL BENEFITS TO WHICH I MAY BE ENTITLED UNDER THE LAW AND I DO HEREBY CERTIFY WITH FULL KNOWLEDGE THAT IT IS A CRIME TO MAKE WILLFUL FALSE STATEMENTS TO OBTAIN COMPENSATION THAT ALL OF MY STATEMENTS ON THIS FORM ARE TRUE ACCURATE AND COMPLETE. DATE AND SIGNATURE MUST be FILLED IN BEFORE MAILING DATE SIGNED SIGNATURE 2 of 3 3030 N. 3rd Street Phoenix AZ 85012-3068 www. scfaz. com Claimant Social Security Number Date of Birth AUTHORIZATION TO RELEASE INFORMATION By this authorization or reproduction thereof I hereby authorize and request any person or organization to allow SCF Arizona or its authorized representative to examine discuss and copy any information records reports and x-rays regarding my medical condition treatment and employment history. Disclosure of medical records for the purpose of administration of workers compensation claims is authorized by the Health Insurance Portability and Accountability Act HIPAA 42 C. AND PERIODS OF UNEMPLOYMENT EMPLOYER NAME AND ADDRESS SHOW UNEMPLOYMENT COMPENSATION PERIODS AND GROSS AMOUNT RECEIVED TYPE OF WORK EMPLOYMENT DATES GROSS EARNINGS BEFORE DEDUCTIONS 1. CURRENT EMPLOYER TYPE OF WORK ADDRESS FROM TO IMPORTANT - FILL IN TOTAL INCOME FOR TWELVE 12 MONTHS BEFORE INJURY REMARKS By THIS INSTRUMENT I MAKE APPLICATION FOR ALL BENEFITS TO WHICH I MAY BE ENTITLED UNDER THE LAW AND I DO HEREBY CERTIFY WITH FULL KNOWLEDGE THAT IT IS A CRIME TO MAKE WILLFUL FALSE STATEMENTS TO OBTAIN COMPENSATION THAT ALL OF MY STATEMENTS ON THIS FORM ARE TRUE ACCURATE AND COMPLETE. DATE AND SIGNATURE MUST be FILLED IN BEFORE MAILING DATE SIGNED SIGNATURE 2 of 3 3030 N. 3rd Street Phoenix AZ 85012-3068 www. scfaz. com Claimant Social Security Number Date of Birth AUTHORIZATION TO RELEASE INFORMATION By this authorization or reproduction thereof I hereby authorize and request any person or organization to allow SCF Arizona or its authorized representative to examine discuss and copy any information records reports and x-rays regarding my medical condition treatment and employment history. SCF Arizona and its subsidiary companies Date P. O. Box 33069 Phoenix AZ 85067-3069 602. 631. 2300 800. 231. 1363 Select Your Insurer SCF Arizona SCF American Insurance Company SCF Casualty Insurance Company SCF General Insurance Company SCF Indemnity Insurance Company WORKERS REPORT OF INJURY AND RELEASE OF MEDICAL INFORMATION SCF National Insurance Company SCF Premier Insurance Company SCF Western Insurance Company Claim Number Date Injured SOCIAL SECURITY NUMBER TELEPHONE NUMBER BIRTH DATE SEX M IF MARRIED IS SPOUSE EMPLOYED ARE YOU MARITAL STATUS Single Married F YES NO RIGHT OR LEFT HANDED LAST DAY WORKED MO/DAY/YR If NO PHONE OR STREET ADDRESS HOW CAN YOU BE LOCATED HAVE YOU RETURNED TO WORK DATE RETURNED TO WORK TREATMENT RECEIVED NAME OF DOCTOR WHO EXAMINED YOU ADDRESS OF DOCTOR WHO EXAMINED YOU DATE OF FIRST TREATMENT CITY DATE OF LAST TREATMENT IF TREATED IN EMERGENCY ROOM NAME OF HOSPITAL GOV T OR V. A. HOSPITAL STATE STILL UNDER TREATMENT NAME OF PHYSICIAN ZIP CODE DATE TREATED INJURY INFORMATION DESCRIBE FULLY HOW YOUR INJURY HAPPENED PARTS OF BODY YOU INJURED ADDRESS OR LOCATION WHERE INJURED HOUR OF INJURY AM PM DATE YOU REPORTED INJURY NAME OF SUPERVISOR INJURY REPORTED TO IF INJURY REPORTED LATE GIVE REASON FOR DELAY WITNESS TO YOUR INJURY GIVE FULL NAME AND ADDRESS. IF NO WITNESSES WRITE NONE. IF INJURY CAUSED BY ANOTHER PERSON GIVE FULL NAME AND ADDRESS OCCUPATIONAL DATA EMPLOYER S Name and ADDRESS OCCUPATION AT TIME OF INJURY WERE YOU EMPLOYED ELSEWHERE AT TIME OF INJURY At TIME OF INJURY WERE YOU A CONTRACTOR SUBCONTRACTOR OR WORK FOR OTHER THAN WAGES DATE HIRED NUMBER OF DAYS WORKED PER WEEK NUMBER OF HOURS WORKED PER DAY LIST EMPLOYMENT DATA ON Page 2 HOURLY WAGE MONTHLY SALARY GENERAL INFORMATION EDUCATION ENTER LAST GRADE COMPLETED GRADE SCHOOL 1 2 3 4 5 6 7 8 YEAR YOU BECAME ARIZONA RESIDENT HIGH SCHOOL 9 10 11 12 STATE YOU MOVED FROM COLLEGE 13 14 15 16 VALID DRIVER S LICENSE LIST FULL NAMES AND ADDRESSES OF PERSONS DEPENDENT ON YOU FOR SUPPORT SPOUSE S NAME IMPORTANT SPOUSE S SOCIAL SECURITY NUMBER All three pages of this form must BE COMPLETED AND SIGNED Preventing DELAY TO ANY BENEFITS TO WHICH YOU MAY BE ENTITLED. 231. 1363 Select Your Insurer SCF Arizona SCF American Insurance Company SCF Casualty Insurance Company SCF General Insurance Company SCF Indemnity Insurance Company WORKERS REPORT OF INJURY AND RELEASE OF MEDICAL INFORMATION SCF National Insurance Company SCF Premier Insurance Company SCF Western Insurance Company Claim Number Date Injured SOCIAL SECURITY NUMBER TELEPHONE NUMBER BIRTH DATE SEX M IF MARRIED IS SPOUSE EMPLOYED ARE YOU MARITAL STATUS Single Married F YES NO RIGHT OR LEFT HANDED LAST DAY WORKED MO/DAY/YR If NO PHONE OR STREET ADDRESS HOW CAN YOU BE LOCATED HAVE YOU RETURNED TO WORK DATE RETURNED TO WORK TREATMENT RECEIVED NAME OF DOCTOR WHO EXAMINED YOU ADDRESS OF DOCTOR WHO EXAMINED YOU DATE OF FIRST TREATMENT CITY DATE OF LAST TREATMENT IF TREATED IN EMERGENCY ROOM NAME OF HOSPITAL GOV T OR V. A. HOSPITAL STATE STILL UNDER TREATMENT NAME OF PHYSICIAN ZIP CODE DATE TREATED INJURY INFORMATION DESCRIBE FULLY HOW YOUR INJURY HAPPENED PARTS OF BODY YOU INJURED ADDRESS OR LOCATION WHERE INJURED HOUR OF INJURY AM PM DATE YOU REPORTED INJURY NAME OF SUPERVISOR INJURY REPORTED TO IF INJURY REPORTED LATE GIVE REASON FOR DELAY WITNESS TO YOUR INJURY GIVE FULL NAME AND ADDRESS. IF NO WITNESSES WRITE NONE. IF INJURY CAUSED BY ANOTHER PERSON GIVE FULL NAME AND ADDRESS OCCUPATIONAL DATA EMPLOYER S Name and ADDRESS OCCUPATION AT TIME OF INJURY WERE YOU EMPLOYED ELSEWHERE AT TIME OF INJURY At TIME OF INJURY WERE YOU A CONTRACTOR SUBCONTRACTOR OR WORK FOR OTHER THAN WAGES DATE HIRED NUMBER OF DAYS WORKED PER WEEK NUMBER OF HOURS WORKED PER DAY LIST EMPLOYMENT DATA ON Page 2 HOURLY WAGE MONTHLY SALARY GENERAL INFORMATION EDUCATION ENTER LAST GRADE COMPLETED GRADE SCHOOL 1 2 3 4 5 6 7 8 YEAR YOU BECAME ARIZONA RESIDENT HIGH SCHOOL 9 10 11 12 STATE YOU MOVED FROM COLLEGE 13 14 15 16 VALID DRIVER S LICENSE LIST FULL NAMES AND ADDRESSES OF PERSONS DEPENDENT ON YOU FOR SUPPORT SPOUSE S NAME IMPORTANT SPOUSE S SOCIAL SECURITY NUMBER All three pages of this form must BE COMPLETED AND SIGNED Preventing DELAY TO ANY BENEFITS TO WHICH YOU MAY BE ENTITLED. C-407 Doc Type IR407 1 of 3 LIST MAJOR INJURIES MEDICAL CONDITIONS OR ILLNESSES BELOW OR DIAGNOSIS DESCRIBE INJURY CONDITION OR ILLNESS BROKEN LEG HERNIATED DISC DIABETES HEART DISEASE ETC.