AGREEMENT TO COMPENSATION OF EMPLOYEE & EMPLOYER State Form 1043 (R3 / 3-09) INDIANA WORKER'S COMPENSATION BOARD 402 West Washington Street, Room W196 Indianapolis, IN 46204 * Your Social Security number is being requested by this state agency in accordance with IC 22-3-4-13; disclosure is voluntary, and you will not be penalized for refusal. Please check appropriate box. Name of employer Address (number and street, city, state, and ZIP code) Name of employee Address (number and street, city, state, and ZIP code) Employee's Social Security number * Telephone number Temporary Total Disability (TTD) Permanent Partial Impairment (PPI) Temporary Partial Disability (TPD) Permanent Total Disability (PTD) Employer's Federal identification number File number Telephone number ( ) ( ) We (employee and employer) have reached an agreement in regards to compensation for the injury sustained by said employee and submit the following statement of facts relative thereto. Date of injury / illness / exposure (month, day, year) Nature of injury / illness / exposure Date disability began (month, day, year) Place of injury / illness / exposure Cause of injury / illness / exposure Probable length of disability The terms of this agreement under the above facts are as follows: That week based upon an average weekly wage of $ bi-weekly) shall receive compensation at the rate of $ per and that said compensation shall be payable (i.e., weekly or until terminated in accordance with the provisions of the Indiana Worker's Compensation / Occupational Disease Acts. If PPI settlement, please provide impairment rating, number of weeks, and amount to be paid. SIGNATURES Signature of employee Signature of employer Name of insurance carrier Address (number and street) City, state, and ZIP code Authorized signature Title Date of agreement (month, day, year) Telephone number Date (month, day, year) Date (month, day, year) (FOR BOARD USE ONLY) ( ) American LegalNet, Inc. www.FormsWorkflow.com