Agreement For Permanent Disability Or Disfigurement Compensation {16}

South Carolina Workers' Compensation Commission 1333 Main Street, Suite 500 P.O. BOX 1715 Columbia, SC 29202-1715 WCC File #: Carrier File #: Carrier Code #: Employer FEIN #: Claimant's Name: Address: City: Home Phone: Preparer's Name: ( ) State: Work Phone: SSN: Employer's Name: Address: Zip: ( ) - City: Carrier: Preparer's Phone #: ( ) - State: Zip: Date of injury: The above-named parties agree to pay and accept compensation based on the following facts: ____ On (month/day/year), the treating physician, (Name of Treating Physician), assigned a percent permanent impairment rating to the medical improvement on (Body Part) and/or and the Claimant accepts average weekly wage of $ Commission. (Body Part). The parties agree that the Claimant reached maximum percent permanent disability to the (month/day/year) and has sustained weeks disfigurement as a result of his/her injury. The Employer's Representative agrees to pay weeks of compensation at the rate of $ . The estimated award is $ , which is based on the Claimant's , which is subject to verification by the Additionally, the employer's representative agrees to pay and the claimant accepts the following medical treatment: ______________________________________________________________________________________________________ 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 authorized by the employer's representative, or specific medical care detailed herein, will be paid under the terms of this agreement. Claimant's Signature Employer's Representative Witness Claimant's Attorney (check one) Commissioner Date Agreement Signed Refer to R.67-804 for instructions regarding the Form 16 WCC Form # 16 Rev. 9/07 Date Approved 16 Agreement for Permanent Disability/ Disfigurement Compensation American LegalNet, Inc. www.FormsWorkFlow.com