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Fill and Sign the State of New Hampshire Department Nhgov Form

Fill and Sign the State of New Hampshire Department Nhgov Form

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THE STATE OF NEW HAMPSHIRE DEPARTMENT OF LABOR CONCORD, NH 03301 MEMO OF PERMANENT IMPAIRMENT AWARD EMPLOYEE NAME EMPLOYEE SOCIAL SECURITY NO. EMPLOYER NAME EMPLOYER FEDERAL IDENTIFICATION NO. INSURANCE CARRIER NAME CARRIER ADJUSTING OFFICE NO. CARRIER ADDRESS CARRIER TELEPHONE NO. DATE OF INJURY DATE OF RETURN TO WORK AVERAGE WEEKLY WAGE AT TIME OF INJURY INJURY DATE COMP. RATE PRESENT EMPLOYER ADDRESS AWARD PERCENTAGE OF PERMANENCY AND BODY PART PI WEEKLY COMP. RATE NO. OF WEEKS OF THE AWARD TOTAL $ AMOUNT OF AWARD DATE OF PERMANENT IMPAIRMENT RATING AWW AT FIRST PI EVALUATION SIGNATURE TITLE DEPARTMENT APPROVAL 10WCA (10/98) SUBJECT TO REVIEW AND APPROVAL BY COMMISSIONER OF LABOR DATE ATTACH MEDICAL REPORT

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