Audit on Death Claims

Name

Average Weekly Wage

Date of Death / HPE Date

Widow?

Yes No

# of Children

Future Comp Rate Full rate used for payout projection (no fall-offs).

Carrier / Employer Paid

Beginning Date	Ending Date	Comp Rate	Days	Total
03/05/2026			0	$0.00
03/05/2026			0	$0.00
03/05/2026			0	$0.00
03/05/2026			0	$0.00
03/05/2026			0	$0.00

Cumulative Date: 12/31/2001

Subtotal (all periods): $0.00

Carrier Paid: $0.00

(Over)/Under: