South Carolina > Workers Comp
Agreement For Permanent Disability Or Disfigurement Compensation 16A - South Carolina
| Agreement For Permanent Disability Or Disfigurement Compensation Form. This is a South Carolina form and can be used in Workers Comp . |
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WCC File #: South Carolina Workers' Compensation Commission 1333 Main Street, Suite 500 Post Office Box 1715 Columbia, South Carolina 29202-1715 (803) 737-5723 www.wcc.sc.gov Claimant's Name: Address: City: Home Phone: Preparer's Name: ( ) State: Work Phone: ( Zip: ) Employer's Name: Address: City: Carrier: Carrier File #: Carrier Code #: Employer FEIN #: State: Zip: Preparer's Phone #: ( ) - This form is only applicable to injuries by accident occurring on or after July 1, 2007 pursuant to Title 42-15-60 (A) as amended. The execution of this document is an agreement between the parties relating to a Workers' Compensation claim under ยงยง42-1-160, 42-1-172 or 42-11-10. Date of Injury or Illness___________ The above parties agree to pay and accept compensation based on the following facts: Injury Illness Repetitive Trauma occurred on: ___________________ (month/day/year). A compensable The injury was to _______________________________________________________________ body part(s) injured and also the injury affected _____________________________________________________________________________________________________ other body part(s). The authorized treating physician has released the Claimant from his or her care and has found maximum medical improvement on ______________________ (month/day/year). with an impairment rating of______________________________________. Average weekly wage ____________________ Compensation rate _______________________ By agreement of the parties, the following award has been referred to the Commission for approval: ____ Percentage loss of use to: _______________________ (body part(s) injured). ____ Percentage loss of use to:________________________(body part(s) affected). ____ Percentage loss of use to: whole person Disfigurement to: ________________________________________________ Wage Loss: $_____amount Total and Permanent Disability: _____________________________________ Other: _________________________________________________________ Estimated award (number of weeks times compensation rate) $ ____________ The estimated award is subject to verification by the Commission Additionally, the Employer's Representative agrees to pay and the Claimant accepts the following medical care and treatment as recommended by the authorized treating physician pursuant to the attached physician's statement, Form 14B Additional medical ordered: _____ Yes _____ No See attached 14B physician's statement dated: ___________________________________ This agreement is binding on approval by the Commission. A claim for additional compensation based on a worsening of the Claimant's condition must be filed no later than one (1) year from the date of the last payment of compensation. Only medical care specifically detailed herein will be paid under this agreement. If a dispute arises with regard to continued medical treatment, either party may request a hearing before the Commission pursuant to 42-15-60(B) 3 and (C). _________weeks _________weeks _________weeks _________weeks _________weeks _________weeks _________weeks ___________________________ Claimant's Signature _________________________ Date Agreement Signed _________________________ Attorney/Witness/Translator _________________________ Employer's Representative _________________________ Attorney for Carrier Date agreement approved _________________________ Email Jurisdictional Commissioner ________________________ Deputy Commissioner _________________________ _________________________ WCC Form # 16A 9/07 16A Agreement for Permanent Disability/ Disfigurement Compensation American LegalNet, Inc. www.FormsWorkFlow.com
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