North Carolina Industrial Commission IC File # EVALUATION FOR PERMANENT IMPAIRMENT Emp. Code # Carrier Code # Carrier File # The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act Employer FEIN ( Employee’s Name Address Employer’s Address ) Employer's Name City ( State ) ( Home Telephone F / Sex City State Zip City State Zip Insurance Carrier ) Work Telephone M Social Security Number Zip Telephone Number Carrier's Address ( / Date of Birth ) ( Carrier's Telephone Number ) Fax Number Date of Injury: EMPLOYEE'S WORK-RELATED INJURY WILL RESULT IN: MEMBER % OF IMPAIRMENT (IF AMPUTATION, DESCRIBE ON REVERSE.) 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) 11) 12) Thumb Index Finger Middle Finger Ring Finger Little Finger Great Toe Toes (other than great toe) Hand Arm Foot Leg Back Physician Signature Printed Name Fed. Tax ID Number Date Address In regard to this rated body part: 1) Is employee at maximum medical improvement? 2) Was employee released with restrictions? TEETH: Age of employee: List all crowns by number : List all extractions by number : Has dental work been completed? Yes _________ _________ No VISION: List vision reading without the use of a corrective lens. Distance: Near: HEARING: Scale used: Percentage of loss: Right ear PLEASE ATTACH AUDIOGRAMS AND CALCULATIONS OF HEARING LOSS OTHER: Permanent injury to or impairment of any other organ or part of body (identify) : Disfigurement: Yes No Location: face head FORM 25R 8/1/08 PAGE 1 OF 2 FORM 25R Left ear body SELF-INSURED EMPLOYER OR CARRIER MAIL TO: NCIC - CLAIMS SECTION 4335 MAIL SERVICE CENTER RALEIGH, NORTH CAROLINA 27699-4335 MAIN TELEPHONE: (919) 807-2500 HELPLINE: (800) 688-8349 WEBSITE: HTTP://WWW.IC.NC.GOV/ American LegalNet, Inc. www.FormsWorkflow.com Rule 405 Computation of Compensation for Amputations Comments: (1) Amputation of any portion of the bone of a distal phalange of a finger or toe at or distal to the visible base of the nail will be considered as equivalent to the loss of one-fourth (1/4) of such finger or toe. (2) Amputation of any portion of the bone of the distal phalange of a finger or toe proximal to the visible base of the nail will be considered as equivalent to the loss of one-half (1/2) of such finger or toe. (3) Amputation through the forearm at a point so distal to the elbow as to permit satisfactory use of a prosthetic appliance with retention of full natural elbow function shall be considered amputation of the hand. Otherwise, it shall be considered amputation of the arm. (4) Amputation through the lower leg at a point so distal to the knee as to permit satisfactory use of a prosthetic appliance with retention of full natural knee function shall be considered amputation of the foot. Otherwise, it shall be considered amputation of the leg. A copy of this form must be provided to the employee or the employee’s attorney of record if any. The original should be mailed to the Industrial Commission at the address below. FORM 25R 8/1/08 PAGE 2 OF 2 FORM 25R SELF-INSURED EMPLOYER OR CARRIER MAIL TO: NCIC - CLAIMS SECTION 4335 MAIL SERVICE CENTER RALEIGH, NORTH CAROLINA 27699-4335 MAIN TELEPHONE: (919) 807-2500 HELPLINE: (800) 688-8349 WEBSITE: HTTP://WWW.IC.NC.GOV/ American LegalNet, Inc. www.FormsWorkflow.com