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  • Ny C-4.3 2021

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Doctor 's Report of MMI/Permanent Partial ImpairmentC4.3Use this form: 1. When rendering an opinion on MMI and/or permanent partial impairment; or 2. In response to a request by the Workers ' Compensation.

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Workers' Compensation coverage is not required if the business is a one or two person owned corporation, with those individuals owning all of the stock and holding all offices of the corporation (each individual must hold an office and own at least one share of stock).

The benefit payable to a totally disabled member is 66 2/3%* of Basic Earnings paid monthly. The monthly benefit payable to a partially disabled member is equal to the percent of pre-disability Basic Earnings lost times the benefit which would have been payable if the member were totally disabled.

If you have a permanent total disability, you are eligible to receive PD payments for the rest of your life.

A 100 percent impairment rating describes a condition limiting an individual's ability to work and perform daily tasks. In such a case, the individual is eligible for total compensation.

Partial disability = Key functions of your occupation, limiting your ability to work full-time in your previous capacity and earning level. Total disability = All of the duties of your occupation or any occupation (depending on your insurance policy terms), preventing you from gainful earnings.

Partial disabilities occur as the result of a wide variety of medical conditions including carpal tunnel syndrome, loss of a body part, hearing loss, knee injuries, nerve damage, PTSD, and loss of vision in a single eye.

Your doctor will assign a disability rating to each affected body part on a scale of zero (0) percent to 100 percent.

Your average weekly wage (AWW) is based on your total gross earnings (not take-home pay) for the 52 weeks before the date of injury or illness, including overtime and other compensation. Your AWW is calculated by dividing your total gross earnings by 52.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232