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Self Insured Employers Permanent Partial Disability Closure Order And Notice (PPD-TL) F207-164-000 - Washington
| Self Insured Employers Permanent Partial Disability Closure Order And Notice (PPD-TL) Form. This is a Washington form and can be used in Self Insurance Workers Comp . |
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SELF INSURED EMPLOYERS PERMANENT PART IAL DISABILITY CLOS URE ORDER AND NOTICE CLAIM DATE OF INJURY UBI NUMBER MAILING DATE TYPE PPD-TL CLAIMANT PHYSICIAN THIS ORDER CONSTITUTES NOTIFICATION THAT YOUR CLAIM IS BEING CLOSED WITH SUCH MEDICAL BENEFITS AND TEMPORARY DISABILITY COMPENSATION AS PROVIDED TO DATE AND WITH SUCH AWARD FOR PERMANENT PARTIAL DISABILITY, IF ANY, AS SET FORTH BELOW, AND WITH THE CONDITION THAT YOU HAVE RETURNED TO WORK WITH THE SELF-INSURED EMPLOYER. IF FOR ANY REASON YOU DISAGREE WITH THE CONDITIONS OR DURATION OF YOUR RETURN TO WORK OR THE MEDICAL BENEFITS, TEMPORARY DISABILITY COMPENSATION PROVIDED, OR PERMANENT PARTIAL DISABILITY THAT HAS BEEN AWARDED, YOU MUST PROTEST IN WRITING TO THE DEPARTMENT OF LABOR AND INDUSTRIES, SELF-INSURANCE SECTION, WITHIN SIXTY DAYS OF THE DATE YOU RECEIVE THIS ORDER. IF YOU DO NOT PROTEST THIS ORDER TO THE DEPARTMENT, THIS ORDER WILL BEC OME FINAL. PROTESTS MUST BE MAILED TO DEPARTMENT OF LABOR AND INDUSTRIES , SELF INSURANCE SECTION, PO BOX 44892, OLYMPIA WA 98504-4892. Time loss compensation and/or loss earnof ing power benefits in thclaimis are ended as paid through This claim is closed effective with award for permanent partial disability as follows: NAME OF SELF-INSURED EMPLOYER IS NOT REQUIRED TO PAY FOR MEDICAL SERVICES OR TREATMENT RENDERED AFTER THE DATE OF CLOSURE. BY FOR (NAME OF SELF-INSURED EMPLOYER) ADDRESS CITY PHONE ( ) F207-164-000
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