Wcc Form 16a - Agreement For Permanent Disability/ Disfigurement Compensation
Download a blank fillable Wcc Form 16a - Agreement For Permanent Disability/ Disfigurement Compensation in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Wcc Form 16a - Agreement For Permanent Disability/ Disfigurement Compensation with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1WCC File #:
South Carolina Workers’ Compensation Commission
Carrier File #:
1333 Main Street, Suite 500 ● Post Office Box 1715
Columbia, South Carolina 29202-1715
Carrier Code #:
(803) 737-5723
Employer FEIN #:
Claimant's Name:
Employer's Name:
Address:
Address:
City:
State:
Zip:
City:
State:
Zip:
Home Phone:
Work Phone:
Carrier:
Preparer's Name:
Preparer’s Phone #:
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 Workers’ Compensation claim
under §§42-1-160, 42-1-172 or 42-11-10.
Date 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 ______________________ (month/day/year).
with an impairment rating of______________________________________.
Average weekly wage $_____________
Compensation rate $_____________
By agreement of the parties, the following award has been referred to the Commission for approval:
____ Percentage loss of use to: _______________________ (body part(s) injured).
_________weeks
____ Percentage loss of use to:________________________(body part(s) affected).
_________weeks
____ Percentage loss of use to: whole person
_________weeks
Disfigurement to: ________________________________________________
_________weeks
Wage Loss: $____________amount
_________weeks
Total and Permanent Disability: _____________________________________
_________weeks
Other: _________________________________________________________
_________weeks
Estimated award (number of weeks times compensation rate) $ ____________
The estimated award is subject to verification by the Commission
Additionally, the Employer’s Representative agrees to pay and the Claimant accepts the following medical care and treatment as recommended
by the authorized treating physician pursuant to the attached physician’s statement, Form 14B
Claimant is entitled to lifetime replacement, repair and
Additional medical ordered:
Yes
No
maintenance of causally related medical hardware
See attached 14B physician’s statement dated: _____________
pursuant to 42-15-60(C).
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 specifically
detailed herein will be paid under this agreement. If a dispute arises with regard to continued medical treatment, either party may request a
hearing before the Commission pursuant to 42-15-60(B) 3 and (C).
___________________________
_________________________
_________________________
Claimant’s Signature
Date Agreement Signed
Attorney/Witness/Translator
_________________________
_________________________
_________________________
Employer’s Representative
Attorney for Carrier
Email
________________________
_________________________
_________________________
Deputy Commissioner
Date Agreement Approved
Jurisdictional Commissioner
WCC Form # 16A
16A
Agreement for Permanent Disability/
9/13
Disfigurement Compensation
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal