Accident No. SUMMARY OF PAYMENTS FATAL CASE Claim No. Injured Person Employe Address Business Address Occupation Premiums paid to Character of Injury Date of Accident Actual Weekly Wages $ Date of Death DEPENDENTS Name of Dependents Relationship Date of Birth (IF UNDER 18) AWARDS OF PAYMENTS Compensation Payments % Wages Amount Weeks Total Remarks SEE ATTACHED RE VISION Total Compensation Payments BURIAL AND OTHER EXPENSES Payment to For Funeral Expenses $ Payment to For Medical Expenses $ Payment to For $ Payment to For $ Total Miscellaneous $ Checked Approved , 20 Auditor CLAIM EXAMINER Claims Mgr. Member