002 002 002 002 002 002 DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS222 COMPENSATION SUPPLEMENTAL AGREEMENT FOR002 COMPENSATION FOR DISABILITY002 OR PERMANENT INJURY002 -- -- EMPLOYEE First name Last name Date of birth Address Address City/Town State ZIP County Telephone INJURY INFORMATION Part of body injured Nature of injury Accident/injury description narrative Check if occupational disease MM DD YYYY EMPLOYER Name Address Address City/Town State ZIP County Telephone FEIN INSURER or THIRD PARTY ADMINISTRATOR (if self-insured) Name Address Address City/Town State ZIP County Telephone FEIN Contact NAIC code or Insurer code Insurer/TPA claim # NOTICE: Agreement should be clearly completed, (preferably typed) and uploaded in accordance with the provisions of the EDI Implementation Guide. A copy must be sent to the employee. Weekly wages must be completed in accordance with the Pennsylvania Workers222 Compensation Act. Whereas, the undersigned employer and employee hereby agree that the status of the employee222s disability changed on as follows: Suspended, returned to work, no loss of wages Termination --MM DD YYYY Said employer shall pay employee compensation at the rate of $ per week beginning on -- MM DD YYYY Compensation is payable for weeks days; or, if the future period of disability is uncertain, then to Judge, or the Workers222 Compensation Appeal Board. American LegalNet, Inc. www.FormsWorkFlow.com 002 002 002 002 002 002 The employee222s new partial compensation is based on the employee222s present weekly earnings and is calculated as follows: Calculation: Average weekly wage at time of injury Minus: Present weekly earnings Subtotal x 2/3= New paFurther matters agreed upon (list any previously unreported periods of compensation and/or actions in chronological order, as well as additional information): We, the undersigned, agree upon the matters represented herein by the above named employee and the above named employer. Employee222s signature (typed/printed) Telephone Date of agreement --MM DD YYYY Employer Information Claims Information Services Email Services Hearing Impaired *337*002 Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program American LegalNet, Inc. www.FormsWorkFlow.com