Form 1043-Agreement To Compensation Of Employee And Employer May 1996
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Indiana Worker's Compensation Board
AGREEMENT TO COMPENSATION
402 West Washington Street, Room W196
OF EMPLOYEE AND EMPLOYER
Indianapolis, Indiana 46204
State Form 1043 (R2 / 5-96)
PRIVACY NOTICE: This agency is requesting disclosure of employee's Social Security number in accordance with IC 22-3-4-13.
Please check appropriate box
Temporary Total Disability (TTD)
Permanent Partial Impairment (PPI)
Temporary Partial Disability (TPD)
Permanent Total Disability (PTD)
Employer's Federal I.D. number
Name of employer
Telephone number
(
)
Address (street, number, city, state and ZIP code)
Employee's Social Security number
Name of employee
Telephone number
(
)
Address (street, number, city, state and ZIP code)
We (employee and employer) have reached an agreement in regards to compensation for the injury sustained by said employee and submit the
following statement of facts relative thereto.
Date of injury / illness / exposure
Nature of injury / illness / exposure
Date disability began
Place of injury / illness / exposure
Cause of injury / illness / exposure
Probable length of disability
The terms of this agreement under the above facts are as follows:
That _________________________________________________ shall receive compensation at the rate of $ _______________________________
per week based upon an average weekly wage of $ _______________________________________________ and that said compensation shall be
payable (i.e., weekly or bi-weekly) ________________________________ until terminated in accordance with the provisions of the Indiana Worker's
Compensation / Occupational Diseaese Acts.
If PPI settlement, please provide impairment rating, number of weeks and amount to be paid
SIGNATURES
Signature of employee
Signature of employer
Name of insurance carrier
Telephone number
(FOR BOARD USE ONLY)
(
)
Address (street and number)
City, state and ZIP code
Authorized signature and title
Date of agreement
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