Injured workers should use this form to request an award for permanent impairment, either physical and/or psychological, resulting from an allowed workers' compensation claim. If an injured worker has a permanent impairment, he or she may be eligible for a monetary award based upon the severity of the impairment. The injured worker may be eligible for this award even if he or she did not lose time from work due to the injury.
If an injured worker has previously been granted a Percentage of Permanent Partial award, he or she can also use this form to request an increase to that award. Increases may be due to the impairment becoming more severe over time or because a new medical condition has been added to the claim.