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AUDIT ON DEATH CLAIMS

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