Ohio > Workers Comp > Industrial Commission
Agreement As To Award For Permanent Total Disability IC-22 - Ohio
| Agreement As To Award For Permanent Total Disability Form. This is a Ohio form and can be used in Industrial Commission Workers Comp . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
AGREEMENTAS TO AWARD FOR PERMANENTTOTALDISABILITY * Type or print clearly and provide all requested information and signatures on both sides of this form. If all parties do not agree on all terms, this application will not be processed per Industrial Commission Rule 41213-34 (C) (3) (a). * Medical evidence substantiating Permanent Total Disability must accompany this form. * Fax this form to 614-466-7472 or file directly with: The Industrial Commission of Ohio Medical Services 30 W. Spring St. 10th floor Columbus Ohio 43215-2233 Injured Worker's Name Address City State Social Security Number Date of Birth Telephone Number ( ) Zip Code Injured worker's last date worked: _______________________ Has the injured worker ever filed for Social Security Disability benefits? Yes If Social Security Disability payments are or were received, provide this information: No Starting Date Rate per month Termination date and reason, if applicable The parties below agree that the above injured worker is permanently and totally disabled due to the allowed conditions of the claims listed below and that an award of permanent total disability compensation should commence effective and be allocated as follows: Date Claim Number Allocation (%) Total = IC-22 100% Page 1 of 2 (rev 10/11) Justice For The Workplace An equal opportunity employer and service provider American LegalNet, Inc. www.FormsWorkFlow.com AGREEMENTAS TO AWARD FOR PERMANENT TOTALDISABILITY BY EXECUTING THIS AGREEMENT, THE PARTIES WAIVE FORMAL HEARING AND ACKNOWLEDGE THAT A COMMISSION ORDER WILL BE ENTERED AFTER DECISION ON THE WRITTEN RECORD. Signature Date Agree/Disagree Injured worker or Attorney Employer or Attorney Employer or Attorney Employer or Attorney Administrator of the Bureau of Workers' Compensation, if any listed claim is state funded or bankrupt self-insured Page 2 of 2 IC-22 (rev 10/11) Justice for the workplace An equal opportunity employer and service provider American LegalNet, Inc. www.FormsWorkFlow.com
|
|||||||
