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Agreement Between Employer And Employee As To Permanent Impairment Form. This is a Maine form and can be use in Workers Compensation.
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Tags: Agreement Between Employer And Employee As To Permanent Impairment, WCB-80, Maine Workers Compensation,
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
:
Index No.
Calendar No.
MAINE WORKERS' COMPENSATION BOARD
:
JUDICIAL
Plaintiff(s)
AUGUSTA, MAINE 04330
-against-
SUBPOENA
:
:
___________________________________
Employee
:
Defendant(s)
:
. . . . . . . . . . . . . . . . . . . . . . . . .vs.. . . . . . . . . . . . . . . . . . . . . . . . . . . .AGREEMENT BETWEEN
.
EMPLOYER AND EMPLOYEE
___________________________________
Employer
THE PEOPLE OF THE STATE OF NEW YORK
AS TO PERMANENT IMPAIRMENT
___________________________________
TO
Insurance Carrier
We, _____________________________________________________________________,
Name of Injured Employee
Residing
GREETINGS: at ___________________________________________________________________,
Street, Number and Town
and WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
_________________________________________________________________________,
Name
,
the Honorable
at theof Employer
Court
located at
County of
of __________________________________________________________________________,
in room
, on the
day of
,Address of Employer
20
, at
o'clock in the
noon, and at any recessed
or adjourned date, to testify and give evidence as a witness in this action on the part of the
have reached an Agreement in permanent impairment for the injury sustained by said employee, and submit the following
statement of facts relative thereto:
Your failure to comply was received on ______________________________________,20__________. you liable to
1.
Said injury with this subpoena is punishable as a contempt of court and will make
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
2.
result of your failure toNature of injury:____________________________________________________________
comply.
_________________________________________________________________________
3.
Extent of
Witness, Honorable permanent impairment: ________% to __________________________(member)
, one of the Justices of the
Court in 4.
County, weekly wages if on salaried20 at time of injury: _______________________
day of
, basis
Employee's
5.
Employee's average weekly wage as per wage schedule attached: _____________________
6.
IT IS AGREED that Permanent Impairment shall be paid in the amount of $_____________
(Attorney must sign above and type name below)
The foregoing Permanent Impairment Agreement is herewith submitted to the Board for approval.
Dated at ____________________ this ___________ day of ___________________________, 20______
Attorney(s) for
______________________________________
Employer
BY ___________________________________
Office and P.O. Address
______________________________________
Employee
Permanent Impairment Agreement must be signed by employee and by employer or a duly authorized representative.
Date: ____________________________________-
Telephone No.:
Facsimile No.:
____________________________________
HEARING OFFICER
E-Mail Address:
Mobile Tel. No.:
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