State Form 1043 "Agreement to Compensation of Employee & Employer" - Indiana

State Form 1043 Printable Pdf
Download pdf Fill PDF online

What Is State Form 1043?

This is a legal form that was released by the Indiana Workers' Compensation Board - a government authority operating within Indiana. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2009;
  • The latest edition provided by the Indiana Workers' Compensation Board;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of State Form 1043 by clicking the link below or browse more documents and templates provided by the Indiana Workers' Compensation Board.

ADVERTISEMENT
ADVERTISEMENT

Download State Form 1043 "Agreement to Compensation of Employee & Employer" - Indiana

Download PDF

Fill PDF online

Rate (4.7 / 5) 99 votes
Show Pagination
Reset Form
INDIANA WORKER’S COMPENSATION BOARD
402 West Washington Street, Room W196
AGREEMENT TO COMPENSATION OF
Indianapolis, IN 46204
EMPLOYEE & EMPLOYER
State Form 1043 (R3 / 3-09)
*
Your Social Security number is being requested by this state agency in accordance with IC 22-3-4-13; disclosure is voluntary, and you will not be penalized for refusal.
Temporary Total Disability (TTD)
Temporary Partial Disability (TPD)
File number
Please check appropriate box.
Permanent Partial Impairment (PPI)
Permanent Total Disability (PTD)
Name of employer
Employer's Federal identification number
Telephone number
(
)
Address (number and street, city, state, and ZIP code)
Name of employee
Employee's Social Security number *
Telephone number
(
)
Address (number and street, city, state, and ZIP code)
We (employee and employer) have reached an agreement in regards to compensation for the injury sustained by said employee and submit the
following statement of facts relative thereto.
Date of injury / illness / exposure (month, day, year)
Date disability began (month, day, year)
Nature of injury / illness / exposure
Place of injury / illness / exposure
Cause of injury / illness / exposure
Probable length of disability
         
The terms of this agreement under the above facts are as follows:
That
shall receive compensation at the rate of $
per
week based upon an average weekly wage of $
and that said compensation shall be payable (i.e., weekly or
bi-weekly)
until terminated in accordance with the provisions of the Indiana Worker's Compensation / Occupational Disease Acts.
If PPI settlement, please provide impairment rating, number of weeks, and amount to be paid.
SIGNATURES
Signature of employee
Date (month, day, year)
Signature of employer
Date (month, day, year)
Name of insurance carrier
Telephone number
(FOR BOARD USE ONLY)
(
)
Address (number and street)
City, state, and ZIP code
Authorized signature
Date of agreement (month, day, year)
Title
Reset Form
INDIANA WORKER’S COMPENSATION BOARD
402 West Washington Street, Room W196
AGREEMENT TO COMPENSATION OF
Indianapolis, IN 46204
EMPLOYEE & EMPLOYER
State Form 1043 (R3 / 3-09)
*
Your Social Security number is being requested by this state agency in accordance with IC 22-3-4-13; disclosure is voluntary, and you will not be penalized for refusal.
Temporary Total Disability (TTD)
Temporary Partial Disability (TPD)
File number
Please check appropriate box.
Permanent Partial Impairment (PPI)
Permanent Total Disability (PTD)
Name of employer
Employer's Federal identification number
Telephone number
(
)
Address (number and street, city, state, and ZIP code)
Name of employee
Employee's Social Security number *
Telephone number
(
)
Address (number and street, city, state, and ZIP code)
We (employee and employer) have reached an agreement in regards to compensation for the injury sustained by said employee and submit the
following statement of facts relative thereto.
Date of injury / illness / exposure (month, day, year)
Date disability began (month, day, year)
Nature of injury / illness / exposure
Place of injury / illness / exposure
Cause of injury / illness / exposure
Probable length of disability
         
The terms of this agreement under the above facts are as follows:
That
shall receive compensation at the rate of $
per
week based upon an average weekly wage of $
and that said compensation shall be payable (i.e., weekly or
bi-weekly)
until terminated in accordance with the provisions of the Indiana Worker's Compensation / Occupational Disease Acts.
If PPI settlement, please provide impairment rating, number of weeks, and amount to be paid.
SIGNATURES
Signature of employee
Date (month, day, year)
Signature of employer
Date (month, day, year)
Name of insurance carrier
Telephone number
(FOR BOARD USE ONLY)
(
)
Address (number and street)
City, state, and ZIP code
Authorized signature
Date of agreement (month, day, year)
Title
Indiana Workers' Compensation Board Indiana Legal Forms United States Legal Forms

Popular Articles

Most popular documents

Featured Tags

Bill of Sale Form U.S. Department of Veterans Affairs United States Army Vehicle Bill of Sale U.S. Department of Defense Boat Bill of Sale Form Firearm Bill of Sale Form Generic Bill of Sale Form
State Form 1043 Printable Pdf
Download pdf Fill PDF online

Related forms

Most popular documents

Related Documents

Popular Articles

Download
Fill PDF online
Upload