DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS222 COMPENSATION DISMEMBERMENT CHART002 SEC. 306(c) WORKERS222 002COMPENSATION ACT AS AMENDED002 EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER -- WCAIS CLAIM NUMBER -- DATE OF INJURY EMPLOYEE First name Last name Date of birth Address Address City/Town State ZIP County Telephone INJURY INFORMATION Part of body injured Nature of injury Accident/injury description narrative Marked by M.D. Check if occupational disease MM DD YYYY EMPLOYER Name Address Address City/Town State ZIP County Telephone FEIN INSURER or THIRD PARTY ADMINISTRATOR (if self-insured) Name Address Address City/Town State ZIP County Telephone FEIN Contact NAIC code or Insurer code Insurer/TPA claim # (OVER) American LegalNet, Inc. www.FormsWorkFlow.com DISMEMBERMENT CHART002 Sec. 306(c) Workers222 Compensation Act as Amended002 The Left Foot (Dorsal surface) Tendo Achillis Cuneiform Mid cuneiform Extensor brevis halluois Dorsal interosseimuscle I II III IV V Cuboid Scaphoid Os Calcis Extensor brevis Ex. cuneiform Peroneus brevis Peroneus tertius METATARSUS FIRST PHALANX SECOND PHALANX THIRD PHALANX Employer Information Claims Information Services Email Services Hearing Impaired *134F*002 Auxiliary aids and services are available upon request to individuals with disabilities.002 Equal Opportunity Employer/Program002 American LegalNet, Inc. www.FormsWorkFlow.com