Name
Date of Injury
# of Children
AWW			66 2/3%	$0.00
			State Max	876

# of Children	COMP RATE	Widow's Rate	Remarriage Lump Sum	Rate Per Child	Tot Children	Tot W/C
0	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00
0	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00
0	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00
0	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00
0	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00
Widow only	$0.00	$0.00	$0.00			$0.00
CHILDREN ONLY
# of Children	COMP RATE	Rate Per Child	Tot Rate For Children
0	$0.00	$0.00	$0.00
0	$0.00	$0.00	$0.00
0	$0.00	$0.00	$0.00
0	$0.00	$0.00	$0.00
0	$0.00	$0.00	$0.00