Statement Of Compensation {219}

Form 219 PERMANENT PARTIAL DISABILITY COMPENSATION WORKSHEET PLEASE PRINT OR TYPE Applicant's Name ________________________________ DOI ____________________________________ Street Address __________________________________ Social Security Number ____________________ City/State, Zip __________________________________ 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). 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 (§34A-2-417). Accrued amounts of compensation will be paid in a lump sum. The remaining amount will be paid as due. If a claimant is represented by an attorney, an "Appointment of Counsel" must be filed by the claimant or attorney. You may use a Form 152 "Appointment of Counsel" to do this. NOTE: Compensation is tax exempt for Federal and State Income Tax purposes. ADJUSTOR NOTE: Forms 122, 123, 141 and the PPI rating are to be maintained by carriers and self-insured employers indefinitely and are to be made available to the Labor Commission upon request. Official Form 219 Revised 6/16 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