Form 219 Revised 6/2007 Utah Labor Commission Division of Industrial Accidents 160 East 300 South, 3rd Floor - P.O. Box 146610 Salt Lake City, UT 84114-6610 (801) 530-6800 - (800) 530-5090 - Fax (801) 530-6804 PERMANENT PARTIAL DISABILITY COMPENSATION AGREEMENT (MUST BE TYPED OR PRINTED) Applicant's Name __________________________________ DOI __________________________ Street Address ___________________________________ Social Security Number _____________ City/State, Zip ____________________________________ DOB __________________________ Employer _______________________________________ Insurance Carrier/Adjusting Service Address________________________________________ City/State/Zip ____________________________ Telephone ______________ Fax _______________ Temporary Total Disability (TTD) Total Paid: __________. _____ No Lost Time. (If no lost time, please attach verification of salary at the time of injury.) Total Number of Lost Work Days: ______ . Temporary Partial Disability (TPD) paid ______ for a total of _______ of which ____________has been paid. Total Medicals Paid to Date __________. Pursuant to the attached medical report and the applicable law, the applicant is entitled to Permanent Partial Disability Compensation (PPD) at the rate of $ _________ per week, commencing _________ for _______ weeks, totaling $ ________, for a _______ % impairment of the ___________ due to his/her industrial injuries, (of which $ ________ has been advanced). In consideration of the above payments, as provided by law, the claimant hereby accepts the compensation paid to date and agrees with the permanent partial impairment rating shown above. However, the Labor Commission shall retain continuing jurisdiction to modify awards as provided by law. Medical expenses incurred as a result of the industrial injury are the continuing obligation of the employer/carrier. For injuries occurring on or after April, 30, 2007, medical care becomes a lifetime benefit so long as the insurance carrier/employer is billed within one year from the date of each medical service. The prior three (3) years statute of limitations if no medical care was incurred or billed within three (3) years still applies to injuries occurring between July 1, 1988 and April 30, 2007. Accrued amounts of compensation will be paid in a lump sum. The remaining amounts will be paid as due. It is understood that this agreement becomes binding and effective only when it is approved by the Labor Commission. ______________________________________ Applicant's Signature Date (Date sent to Applicant __________________) ________________________________________ Adjustor's Name (Please type or print) Adjustor’s E-mail Address _______________________ Adjustor’s Signature _________________Date _______ The above Compensation Agreement has been reviewed and is approved by the Labor Commission. Attorney's fees of $_____should be deducted from the amounts owing and paid by the carrier/employer to the attorney ______________________________. (Form 152 must be filed) (Please type or print) ___________________________________________ Labor Commission Date NOTE: Compensation is tax exempt for Federal and State Income Tax purposes. ADJUSTOR NOTE: Required documentation: 3 copies of the signed agreement and 1 each of the Forms 122, 123, 141 and the PPI rating – highlighted (5th Edition). No Lost Time will require proof of wages. If unsigned by applicant, must have explanation. Pre-addressed return envelopes (typed) for yourself and the claimant are required. American LegalNet, Inc. www.FormsWorkflow.com