Agreement For Permanent Disability Or Disfigurement Compensation {16A}

1333 Main Street , Suite 500 Columbia, South Carolina 29202 - 1715 (803) 737 - 5723 www.wcc.sc.gov WCC File #: Carrier File #: Carrier Cod e #: Claimant's Name: Address: City: State: Zip: Home Phone: Work Phone: Preparer's Name: Employer's Name: Address: City: State: Zip: Carrier: 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 WorkersDate of Injury or Illness The above parties agree to pay and accept compensation based on the following facts: A compensable Injury Illness Repetitive Trauma occurred on: (month/day/year). 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 Date greement pproved Jurisdictional Commissioner WCC Form # 16A 16A Agreement for Permanent Disability/ Disfigurement Compensation American LegalNet, Inc. www.FormsWorkFlow.com