WCC File #: South Carolina Workers’ Compensation Commission 1333 Main Street, Suite 500 P.O. BOX 1715 Columbia, SC 29202-1715 Carrier File #: Carrier Code #: Employer FEIN #: Claimant's Name: SSN: Employer's Name: Address: Address: City: Home Phone: State: ( ) - Work Phone: Zip: ( ) City: - State: Zip: Carrier: Preparer's Name: Preparer’s Phone #: ( ) - Date of injury: ____ The above-named parties agree to pay and accept compensation based on the following facts: On (month/day/year), the treating physician, percent permanent impairment rating to the medical improvement on (Body Part) and/or (Name of Treating Physician), assigned a (Body Part). The parties agree that the Claimant reached maximum (month/day/year) and has sustained percent permanent disability to the weeks disfigurement as a result of his/her injury. The Employer’s Representative agrees to pay and the Claimant accepts weeks of compensation at the rate of $ average weekly wage of $ . The estimated award is $ , which is based on the Claimant’s , which is subject to verification by the Commission. Additionally, the employer’s representative agrees to pay and the claimant accepts the following medical treatment: ______________________________________________________________________________________________________ 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 authorized by the employer’s representative, or specific medical care detailed herein, will be paid under the terms of this agreement. Claimant’s Signature Witness Employer’s Representative Claimant’s Attorney (check one) Commissioner Date Agreement Signed Date Approved Refer to R.67-804 for instructions regarding the Form 16 WCC Form # 16 Rev. 9/07 16 Agreement for Permanent Disability/ Disfigurement Compensation American LegalNet, Inc. www.FormsWorkFlow.com