002 002002 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 002 002 002 002 002 DISMEMBERMENT CHART002 Sec. 306(c) Workers222 Compensation Act as Amended002 Metacarpus Hamate Triquetral Capitate Trapezoid Carpus Pisiform Employer Information Claims Information Services Email Services Hearing Impaired *134*002 Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program American LegalNet, Inc. www.FormsWorkFlow.com