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