DEATH BENEFITS

Applicant Name

Date of Death (mm/dd/yyyy)

Date of Calculation

(mm/dd/yyyy)

Total Dependents

Partial Dependents

DOB of Youngest Child(mm/dd/yyyy)

Weekly Earnings

Interest Rate

SAWW

Annual Support for all Partial Dependents

Actual Burial Expense

Attorney Fee Calculation Methods

Uniform Reduction

Far off End

Amount Due Payments

Past Due Payments Paid at Correct Rate

Past Due Payments Paid at Current Rate

Attorney Fee %