Form 1043 - Agreement To Compensation Of Employee & Employer
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INDIANA WORKER’S COMPENSATION BOARD
402 West Washington Street, Room W196
AGREEMENT TO COMPENSATION OF
Indianapolis, IN 46204
EMPLOYEE & EMPLOYER
State Form 1043 (R3 / 3-09)
*
Your Social Security number is being requested by this state agency in accordance with IC 22-3-4-13; disclosure is voluntary, and you will not be penalized for refusal.
Temporary Total Disability (TTD)
Temporary Partial Disability (TPD)
File number
Please check appropriate box.
Permanent Partial Impairment (PPI)
Permanent Total Disability (PTD)
Name of employer
Employer's Federal identification number
Telephone number
(
)
Address (number and street, city, state, and ZIP code)
Name of employee
Employee's Social Security number *
Telephone number
(
)
Address (number and street, 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 (month, day, year)
Date disability began (month, day, year)
Nature of injury / illness / exposure
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 Disease Acts.
If PPI settlement, please provide impairment rating, number of weeks, and amount to be paid.
SIGNATURES
Signature of employee
Date (month, day, year)
Signature of employer
Date (month, day, year)
Name of insurance carrier
Telephone number
(FOR BOARD USE ONLY)
(
)
Address (number and street)
City, state, and ZIP code
Authorized signature
Date of agreement (month, day, year)
Title
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Parent category: Business