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 Include the following if applicable American LegalNet, Inc. www.FormsWorkFlow.com choose the appropriate paragraphORchoose the appropriate paragraphenter amount of total paymententer amount of indemnityenter amount of medicalenter CCP rateORenter amount of total paymententer amount of total payment that will be made by WAMOenter amount of total payment that will be made by American LegalNet, Inc. www.FormsWorkFlow.com 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 amount of indemnityenter amount of medicalenter 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 inapplicablechoose the appropriate paragraph and delete inapplicable sectionsenter date of CMS approval letterenter approved MSA amount American LegalNet, Inc. www.FormsWorkFlow.com . Or other entity or address as designated by CMS Or other entity or address as designated by CMSORselect one of the following paragraphsenter amount allocated to medical expensesORIf the allocation for medical expenses is $0, use this paragraph American LegalNet, Inc. www.FormsWorkFlow.com Delete if inapplicableenter claimant222s date of birthenter the claimant222s life expectancy in years enter claimant222s life expectancy in months enter indemnity settlement amount excluding legal feeenter indemnity settlement amount excluding legal fee divided by claimant222s life expectancy in months choose the appropriateparagraphsenter amount of WAMO222s paymentMatter 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