April 20, 2004

INSURANCE INFORMATION NOTICE 2004-2

STOP USING E-2 FORM FOR

PRE-EXISTING MEDICAL INJURY/ILLNESS

Due to issues raised in response to the recently revised E-2 form, we are currently re-evaluating this form. Effective immediately, stop using either version of E-2 Form to obtain information regarding pre-existing medical injuries or illnesses from employees, including new hires. Until further notice, no medical inquires should be made to any employee or new hire regarding pre-existing injuries or illnesses relating to the Second Injury Fund. A new E-2 form, along with written policies and procedures to govern its use, will be distributed in the near future.

ACTION REQUIRED: Any Revised E-2 forms that have been obtained from employees since July 1, 2003 should be destroyed by the Human Resource Manager, Director or senior staff person in charge of the human resource function for your agency, no later than May 15, 2004.

If you have any questions, please contact Karen Jackson at (225) 342-7390.