RESET
SELF INSURED EMPLOYERS' PERMANENT PARTIAL DISABILITY CLOSURE ORDER AND NOTICE
CLAIM CLAIMANT
DATE OF INJURY
UBI NUMBER
MAILING DATE
TYPE
PPD-TL
PHYSICIAN
THIS ORDER CONSTITUTES NOTIFICATION THAT YOUR CLAIM IS BEING CLOSED WITH SUCH MEDICAL BENEFITS AND TEMPORARY DISABILITY COMPENSATION AS PROVIDED TO DATE AND WITH SUCH AWARD FOR PERMANENT PARTIAL DISABILITY, IF ANY, AS SET FORTH BELOW, AND WITH THE CONDITION THAT YOU HAVE RETURNED TO WORK WITH THE SELF-INSURED EMPLOYER. IF FOR ANY REASON YOU DISAGREE WITH THE CONDITIONS OR DURATION OF YOUR RETURN TO WORK OR THE MEDICAL BENEFITS, TEMPORARY DISABILITY COMPENSATION PROVIDED, OR PERMANENT PARTIAL DISABILITY THAT HAS BEEN AWARDED, YOU MUST PROTEST IN WRITING TO THE DEPARTMENT OF LABOR AND INDUSTRIES, SELF-INSURANCE SECTION, WITHIN SIXTY DAYS OF THE DATE YOU RECEIVE THIS ORDER. IF YOU DO NOT PROTEST THIS ORDER TO THE DEPARTMENT, THIS ORDER WILL BECOME FINAL. PROTESTS MUST BE MAILED TO DEPARTMENT OF LABOR AND INDUSTRIES, SELF INSURANCE SECTION, PO BOX 44892, OLYMPIA WA 98504-4892.
Time loss compensation and/or loss of earning power benefits in this claim are ended as paid through
This claim is closed effective
with award for permanent partial disability as follows:
NAME OF SELF-INSURED EMPLOYER
IS NOT REQUIRED TO PAY FOR MEDICAL SERVICES OR TREATMENT RENDERED AFTER THE DATE OF CLOSURE.
BY FOR (NAME OF SELF-INSURED EMPLOYER) ADDRESS CITY PHONE ( )
F207-164-000