Maine > Workers Compensation
Agreement Between Employer And Employee As To Permanent Impairment WCB-80 - Maine
| Agreement Between Employer And Employee As To Permanent Impairment Form. This is a Maine form and can be used in Workers Compensation . |
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MAINE WORKERS COMPENSATION BOARD AUGUSTA, MAINE 04330 ___________________________________ Employee vs. AGREEMENT BETWEEN EMPLOYER AND EMPLOYEE ___________________________________ Employer AS TO PERMANENT IMPAIRMENT ___________________________________ Insurance Carrier We, _____________________________________________________________________, Name of Injured Employee Residing at ____________________________________________________________ _______, Street, Number and Town and ____________________________________________________________________ _____, Name of Employer of _____________________________________________________________________ _____, Address of Employer have reached an Agreement in permanent impairment for the injury sustained by said employee, and submit the following statement of facts relative thereto: 1. Said injury was received on ______________________________________,20__________. 2. Nature of injury:____________________________________________________________ ________________________________________________________________________ _ 3. Extent of permanent impairment: ________% to __________________________(member) 4. Employees weekly wages if on salaried basis at time of injury: _______________________ 5. Employees average weekly wage as per wage schedule attached: _____________________ 6. IT IS AGREED that Permanent Impairment shall be paid in the amount of $_____________ The foregoing Permanent Impairment Agreement is herewith submitted to the Board for approval. Dated at ____________________ this ___________ day of ___________________________, 20______ ______________________________________ Employer BY ___________________________________ ______________________________________ Employee Permanent Impairment Agreement must be signed by employee and by employer or a duly authorized representative. Date: ____________________________________- ____________________________________ HEARING OFFICER
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