Claim Number Allocation (%) 100% Total: Injured Worker222s Information Name Date of Birth Address City, State, Zip Name Injured Worker222s Representative Information Telephone Fax Telephone Fax Rep ID# IC-22An Equal Opportunity Employer and Service ProviderTimely, impartial resolution to workers222 compensation appeals Rev. (10.18) Instructions:Type or print clearly and provide all requested information and signatures.If all parties do not agree on all terms, this application will not be processed per Industrial CommissionRule 4121-3-34 (C) (3) (a).Medical evidence substantiating PermanentTotal Disability must accompany this form.DateAdministrator of Bureau of Workers222 Compensation (if applicable) Date Claim Number: AGREEMENT AS TO AWARD FOR PERMANENT TOTAL DISABILITY Injured Worker222s last date worked: (mm/dd/yyyy) Has the injured worker ever filed for Social Security Disability benefits? Yes No If 223Yes224 and Social Security Disability payments were received, provide the information below: (mm/dd/yyyy)Starting Date Rate Per Month$ Termination Date(mm/dd/yyyy)Termination Reason (if applicable): The parties below agree that the above injured worker is permanently and totally disabled due to the allowed conditions of the claims listed below and that an award of permanent total disability compensation should commence effective and be allocated as follows:Agree DisagreeAgree DisagreeBy executing this agreement, the parties waive formal hearing and acknowledge that a commission order will be entered after decision on the written record.Date Agree Disagree Employer or Attorney222s Signature (required)Date Agree DisagreeInjured Worker or Attorney222s Signature (required)Date Agree Disagree (mm/dd/yyyy)Employer or Attorney222s SignatureEmployer or Attorney222s Signature American LegalNet, Inc. www.FormsWorkFlow.com