Form 44 (Order to Second Injury Fund in Cases of Concurrent Employment)


TO: Commissioners, District Administrators, Self-Insureds, Insurance Carriers, Attorneys, Unions, Second Injury Fund, and Advisory Board Members
FROM: John A. Mastropietro, Chairman
DATE: March 11, 2004
RE: Form 44 (Order to Second Injury Fund in Cases of Concurrent Employment)


In the past, the carrier has submitted the completed form 44 requesting approval from the commission to seek reimbursement from the Second Injury Fund. Once a commissioner approved it, the form was then forwarded to the Second Injury Fund for reimbursement to the carrier.

Effective April 1, 2004, the following change will take place: the carrier will send the completed form 44 to the Second Injury Fund for their signature. Once both parties agree on the figures and sign the form, it should then be submitted to the appropriate workers’ compensation district for approval by a commissioner. Approved copies will then be mailed to the parties. A hearing may be scheduled if there are any unexplained discrepancies, e.g., figures on the form 44 vs. the approved Voluntary Agreement or if no Voluntary Agreement has been filed. In changing this procedure, we believe that we can eliminate the scheduling of many unnecessary hearings.

In conjunction with this new procedure, we have amended the form 44. For your convenience, this newly revised form can be filled out and downloaded from our website at: