Fill and Sign the Form 20 South Carolina Workers Compensation Commission

S outh C arolina Workers’ Compensation Commission 1333 Main Street, Suite 500 P.O. BOX 1715 Columbia, SC 29202 - 1715 WCC File #: Carrier File #: Carrier Code #: Employer FEIN # : Claimant's Name: SSN: Address: City: State: Zip: Home Ph one : Work Phone: Preparer's Name: Employer's Name: Address: City: State : Zip: Carrier: Preparer’s Phone #: Date of injury: ____ The above-named parties agree to pay and accept compensation based on the following facts: _________________________ (Name of Treating Physician) , assigned a percent permanent impairment rating to the ________________________ (Body Part) . The parties agree that the Clai mant reached maximum medical improvement on (month/day/year) and has sustained percent permanent disability to the ___________________ (Body Part) and/or weeks disfigurement as a result of his/her injury. The Employer’s Representative agrees to pay and the Claimant accepts weeks of compensation at the rate of $ , which is based on the Claimant’s average weekly wage of $ . The estimated award is $ On , which is subject to verification by the Commission. (month/day/year) , the treating physician, Additionally, the employer’s representative agrees to pay and the claimant accepts the following medica l treatment: ______________________________________________________________________________________________________ This agreement is binding on approval by the Commission. A claim for additional compensation based on a worsening of the Claimant’s condition must be filed no later than one (1) year from the date of the last payment of compensation. Only medical care authorized by the employer’s representative, or specific medical care detailed herein, will be paid under the terms of t his agreement. Claiman t’s Signature Employer’s Representative Witness Claimant’s Attorney (check one) Commissioner Date Agreement Signed Date Approved Refer to R.67 -804 for ins tructions regarding the Form 16 WCC Form # 16 Rev. 9/0 7 16 Agreement for Permanent Disability/ Disfigurement Compensation