 |
|
| Rating Schedule |
|
|
|
Date
of Birth
(mm/dd/yyyy)
|
|
Date
of Injury
(mm/dd/yyyy)
|
|
Age at DOI |
Weekly Earnings |
|
| GroupNo
|
|
|
| Description |
|
WPI |
|
| Apportion |
|
|
|
| | Apportion | ImpairmentNo | WPI | FECRank | FECAdj | GroupNo | GroupLetter | OccupAdj | AgeAdj | Right/Left | AfterApportion |
|
|
| PD of same extremity regions
combined:
|
| Final Combined PD:
|
|
|
Weekly Payment and Total Amount |
| Weekly Rate
|
First Day
|
Last Day |
Days |
Daily Rate |
Amount |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
P & S Date |
|
Weeks |
|
|
|
Job Offer Date |
|
Total |
|
|
|
|
|
Life Pension |
|
|
|
|