Agreement As To Compensation For Permanent Partial Disability {OIC 3013}

Claim Number: AGREEMENT AS TO COMPENSATION FOR PERMANENT PARTIAL DISABILITY Injured Worker's Information Name Address City, State, Zip Telephone Fax Name Address City, State, Zip Telephone Fax Employer's Information Injured Worker's Representative's Information Rep ID# Name Telephone Fax Rep ID# Name Employer's Representative's Information Telephone Fax AGREEMENT This agreement is entered into by and between all interested parties under the authority granted by the Industrial Commission of Ohio and is subject to such change and modifications as may be ordered by the Industrial Commission of Ohio. Therefore, we, the below signed parties, hereby agree that the Injured Worker sustained an injury on (mm/dd/yyyy) and that the said claim has been recognized for It is further agreed that the Injured Worker has a percentage of permanent partial disability of %, which would entitle him/her to an award for the period of weeks; that if the date of injury in this claim is prior to 08/22/1986, the Injured Worker must elect whether to receive compensation as above determined or to be compensated for impairment of earning capacity; and, that the Injured Worker's average weekly wage is $ which would entitle him/her to a rate of $ per week. It is further agreed that the Injured Worker's percentage of permanent partial disability has increased and is now which is an increase of %; therefore, that he/she is entitled to an additional award of compensation for the period of him/her to a rate of $ weeks; and, that the injured worker's average weekly wage is $ per week. which would entitle %, It is further agreed that the Injured Worker has sustained the loss by amputation or ankylosis or the permanent total loss of use of ; therefore, that such loss would entitle him/her to an award for the period of weeks; and, that the statewide average weekly wage is $ which would entitle him/her to a rate of $ per week. WAIVER OF NOTICE OF HEARING AND WAIVER OF RIGHT OF APPEAL So that the Injured Worker herein may promptly receive payment of his/her award, the parties hereto waive notice of hearing on the application filed AND further waive their right to appeal an order entered pursuant to this agreement. (mm/dd/yyyy) By checking this box, I certify that I am a non-attorney representative who has been authorized and directed to file this agreement by the Injured Worker Employer. READ THIS DOCUMENT CAREFULLY BEFORE SIGNING. BY EXECUTING THIS DOCUMENT YOU HAVE WAIVED YOUR RIGHT TO A HEARING, WAIVED YOUR RIGHT TO FILE AN OBJECTION/APPEAL, AND HAVE AGREED TO THE PAYMENT OF PERMANENT PARTIAL DISABILITY COMPENSATION. Injured Worker or Representative Employer or Representative An Equal Opportunity Employer and Service Provider Timely, impartial resolution of workers' compensation appeals OIC 3013 BWC Administrator (Rev. 06/12) ICGC1 American LegalNet, Inc. www.FormsWorkFlow.com