When a Pennsylvania work injury causes loss of toes or part of the foot, this Bureau of Workers' Compensation chart documents the level of amputation for specific-loss benefits under Section 306(c). The physician marks a labeled diagram of the dorsal surface of the foot, showing tarsal bones, metatarsals and the toe phalanges. Page one links the chart to the WCAIS claim and the injury.
A physician marks the foot diagram and is identified in the 'Marked by M.D.' block. The form does not say who completes the employee, employer, insurer and injury fields on page one.
Download the current version from the source each time; forms change without notice.
Dismemberment Chart (Foot)
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
The diagram on page two shows the dorsal surface of the left foot only. The physician marks the level of loss on that drawing, and the injury information on page one, including the part of body injured, the nature of injury and the accident narrative, describes the injury itself.
It supports specific-loss benefits under Section 306(c) of the Pennsylvania Workers' Compensation Act, which the chart names in its heading. By marking the exact amputation level on the foot diagram, the physician gives the parties the anatomical detail needed to identify which specific loss applies.