Name
Average Weekly Wage
Date of Death
Rounded
Widow?
Yes
No
$0.00
Widow's Rate
$0.00
# of children
$0.00
Rate per Child
$0.00
Maximum Comp Rate
$0.00
$0.00
Total Rate
$0.00
Future Comp Rate
See Apportionment
Beginning Date
Ending Date
Comp Rate
Days
Total
1/2/2000
0
$0.00
1/2/2000
0
$0.00
1/2/2000
0
$0.00
1/2/2000
0
$0.00
1/2/2000
0
$0.00
 
Total
$0.00
Carrier Paid
Liability
$0.00
(over)/under
$0.00
Remaining Liability
$0.00
Days to Pay Out
0
Payout Date
0/0/00
Partial Payment
$0.00
Partial Pay Date
0/0/00
Trust Fund Liability Date
0/0/00