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APPORTIONMENT - WIDOW WITH CHILDREN ONLY

Name    
Date of Injury                  
# of Children      
AWW   66 2/3% $0.00
      State Max 617.00
# 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

This sheet is designed to calculate the entitlements for Death claims involving widow and children who are wholy and actually dependent. It will provide the appropriate compensation rates for the average weekly wage entered and the year of the Injury/Death.