Utah > Workers Compensation
Permanent Partial Disability Agreement 219 - Utah
| Permanent Partial Disability Agreement Form. This is a Utah form and can be used in Workers Compensation . |
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Print Form Form 219 PERMANENT PARTIAL DISABILITY COMPENSATION AGREEMENT PLEASE PRINT OR TYPE Applicant's Name ______________________________ Street Address ________________________________ City/State, Zip ________________________________ DOI _____________________________________ Social Security Number _____________________ DOB ____________________________________ Employer ____________________________________________________________________________________ Insurance Carrier/Adjusting Service Address _____________________________________________________ City/State/Zip ___________________________________ Telephone ______________ Fax _________________ Temporary Total Disability (TTD) Total Paid: __________. _____ No Lost Time. (If no lost time, please attach verification of salary at the time of injury.) Total Number of Lost Work Days: ______. Temporary Partial Disability (TPD) paid _____________ for a total of _______ of which ________has been paid. Total Medicals Paid to Date __________. Pursuant to the attached medical report and the applicable law, the applicant is entitled to Permanent Partial Disability Compensation (PPD) at the rate of $ ___________ per week, commencing _____________ for _________ weeks, totaling $ _______________, for a _________ % impairment of the ______________________ due to his/her industrial injuries, (of which $ ______________ has been advanced). In consideration of the above payments, as provided by law, the claimant hereby accepts the compensation paid to date and agrees with the permanent partial impairment rating shown above. However, the Labor Commission shall retain continuing jurisdiction to modify awards as provided by law. Medical expenses incurred as a result of the industrial injury are the continuing obligation of the employer/carrier. Medical care becomes a lifetime benefit so long as the insurance carrier/employer is billed within one year from the date of each medical service. Accrued amounts of compensation will be paid in a lump sum. The remaining amounts will be paid as due. It is understood that this agreement becomes binding and effective only when it is approved by the Labor Commission. _________________________________ ____________________________________ Applicant's Signature Date Adjustor's Name (Please type or print) (Date sent to Applicant __________________) ______________________________________________ Adjustor's E-mail Address ______________________________________________ Adjustor's Signature Date The above Compensation Agreement has been reviewed and is approved by the Labor Commission. Attorney's fees of $_____ should be deducted from the amounts owing and paid by the carrier/employer to the attorney _____________________________. (Please print) (Form 152 must be filed) _____________________________________________________ Labor Commission Date NOTE: Compensation is tax exempt for Federal and State Income Tax purposes. ADJUSTOR NOTE: Required documentation: 3 copies of the signed agreement and 1 each of the Forms 122, 123, 141 and the PPI rating highlighted (5th Edition). No Lost Time will require proof of wages. If unsigned by applicant, must have explanation. Pre-addressed return envelopes (typed) for yourself and the claimant are required. Official Form 219 Revised 2/10 State of Utah Labor Commission Division of Industrial Accidents 160 East 300 South P.O. Box 146610 Salt Lake City, UT 84114-6610 Telephone: (801) 530-6800 Fax: (801) 530-6804 Toll Free: (800) 530-5090 www.laborcommission.utah.gov American LegalNet, Inc. www.FormsWorkFlow.com
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