Free MAINE WORKERS' COMPENSATION BOARD - Maine

MAINE WORKERS' COMPENSATION BOARD AUGUSTA, MAINE 04330

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Employee

vs.

AGREEMENT BETWEEN EMPLOYER AND EMPLOYEE

___________________________________
Employer

AS TO PERMANENT IMPAIRMENT

___________________________________
Insurance Carrier

We, _____________________________________________________________________,
Name of Injured Employee

Residing at ___________________________________________________________________,
Street, Number and Town

and _________________________________________________________________________,
Name of Employer

of __________________________________________________________________________,
Address of Employer

have reached an Agreement in permanent impairment for the injury sustained by said employee, and submit the following statement of facts relative thereto: 1. 2. Said injury was received on ______________________________________,20__________. Nature of injury:____________________________________________________________ _________________________________________________________________________ 3. 4. 5. 6. Extent of permanent impairment: ________% to __________________________(member) Employee's weekly wages if on salaried basis at time of injury: _______________________ Employee's average weekly wage as per wage schedule attached: _____________________ IT IS AGREED that Permanent Impairment shall be paid in the amount of $_____________

The foregoing Permanent Impairment Agreement is herewith submitted to the Board for approval. Dated at ____________________ this ___________ day of ___________________________, 20______ ______________________________________ Employer BY ___________________________________ ______________________________________ Employee Permanent Impairment Agreement must be signed by employee and by employer or a duly authorized representative.

Date: ____________________________________-

____________________________________ HEARING OFFICER