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Dismemberment Chart (Hand) Form. This is a Pennsylvania form and can be use in Workers Comp.25,000 Minor Permanent Partial cases; and 40,000 Temporary Total injury cases. 3.1 Objectives for Determining Impairment for Hand and Wrist . The following table shows losses that are covered and the corresponding benefit amount, which is shown as a percentage of the total coverage. For some losses, the full coverage amount is payable; for others, a portion of the coverage amount is payable. The page navigation is complete. One of the definitions of permanent total disability is dismemberment or loss of use of both arms, legs, hands, feet, eyes or any combination of those five. The page navigation is complete. Accidental Death and Dismemberment insurance.