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PERMANENT TOTAL DISABILITY FORM AR-D AUDIT

Name  
DATE OF INJURY    
HPE date/Date of Death    
Average Weekly Wage $0.00 (66 2/3%)
Compensation Rate $0.00    
 
Liability $0.00    
Days to Pay Out 0    
Payout Date 0/0/00    
Partial payment $0.00    
Partial payment date 0/0/00    
 
Cumulative Date    
Cumulative Days 0    
Cumulative Total $0.00    
Carrier/Emp Paid    


 
(OVER)/UNDER $0.00    
 
 
Trust Fund Liability Date 0/0/00    

Use the Disability Date for the Date of Injury if it occurred in a year other than the Date of Injury. The spreadsheet will apply the lower of 66 2/3% or the State Maximum Rate for the year of the Injury. Entry of your actual amounts paid will show current status against amounts due. You will need to change the Cumulative Date on an annual basis to correspond with your filing.