enter claimant222sWCB Case Noenter claimant222s date of accident/occupational diseaseenter all sites of injuries for this caseenter AWWenter CCP rateenter percentage of 15(8) reimbursement repeat this paragraph for all claims included in the agreement and specify apportionment if applicable American LegalNet, Inc. www.FormsWorkFlow.com choose the appropriate paragraphORchoose the appropriate paragraphenter amount of total paymententer CCP rate American LegalNet, Inc. www.FormsWorkFlow.com ORenter amount of total paymententer amount of total payment that will be made by WAMOenter amount of total payment that will be made by another party/insurer (and repeat if needed)enter name of other party/insurer making paymentspecify whether the payment is in this case or, if in other WCB case numbers, include other WCB case numbersenter CCP rateenter amount of legal feeenter WAMO or whichever other party is paying the fee if not WAMOenter name of legal representative hereenter gross settlement amount excluding legal feeDelete if inapplicableenter claimant222s date of birthenter the claimant222s life expectancy in years enter the claimant222s life expectancy in months enter gross settlement amount excluding legal feeenter gross settlement amount excluding legal fee divided by claimant222s life expectancy in months American LegalNet, Inc. www.FormsWorkFlow.com Matter of Kelly v State Insurance FundMatter of Burns v VarrialeMatter of Bissell v Town of Amherst American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com