Free F207-164-000 self insured employers permanent partial disability closure order and notice PPD-TL - Washington


File Size: 78.7 kB
Pages: 1
Date: July 26, 2005
File Format: PDF
State: Washington
Category: Workers Compensation
Author: rilj235
Word Count: 228 Words, 1,446 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.lni.wa.gov/Forms/pdf/207164af.pdf

Download F207-164-000 self insured employers permanent partial disability closure order and notice PPD-TL ( 78.7 kB)


Preview F207-164-000 self insured employers permanent partial disability closure order and notice PPD-TL
RESET
SELF INSURED EMPLOYERS' PERMANENT PARTIAL DISABILITY CLOSURE ORDER AND NOTICE

CLAIM CLAIMANT

DATE OF INJURY

UBI NUMBER

MAILING DATE

TYPE

PPD-TL

PHYSICIAN

THIS ORDER CONSTITUTES NOTIFICATION THAT YOUR CLAIM IS BEING CLOSED WITH SUCH MEDICAL BENEFITS AND TEMPORARY DISABILITY COMPENSATION AS PROVIDED TO DATE AND WITH SUCH AWARD FOR PERMANENT PARTIAL DISABILITY, IF ANY, AS SET FORTH BELOW, AND WITH THE CONDITION THAT YOU HAVE RETURNED TO WORK WITH THE SELF-INSURED EMPLOYER. IF FOR ANY REASON YOU DISAGREE WITH THE CONDITIONS OR DURATION OF YOUR RETURN TO WORK OR THE MEDICAL BENEFITS, TEMPORARY DISABILITY COMPENSATION PROVIDED, OR PERMANENT PARTIAL DISABILITY THAT HAS BEEN AWARDED, YOU MUST PROTEST IN WRITING TO THE DEPARTMENT OF LABOR AND INDUSTRIES, SELF-INSURANCE SECTION, WITHIN SIXTY DAYS OF THE DATE YOU RECEIVE THIS ORDER. IF YOU DO NOT PROTEST THIS ORDER TO THE DEPARTMENT, THIS ORDER WILL BECOME FINAL. PROTESTS MUST BE MAILED TO DEPARTMENT OF LABOR AND INDUSTRIES, SELF INSURANCE SECTION, PO BOX 44892, OLYMPIA WA 98504-4892.
Time loss compensation and/or loss of earning power benefits in this claim are ended as paid through

This claim is closed effective

with award for permanent partial disability as follows:

NAME OF SELF-INSURED EMPLOYER

IS NOT REQUIRED TO PAY FOR MEDICAL SERVICES OR TREATMENT RENDERED AFTER THE DATE OF CLOSURE.
BY FOR (NAME OF SELF-INSURED EMPLOYER) ADDRESS CITY PHONE ( )

F207-164-000