Date of Injury Select Date of Injury: 1. Medical Expenses Paid by Insurance ($): Outstanding ($): Total Medical Expenses: $0.00 2. Transportation Costs Round-trip Mileage per Visit: Number of Visits: Total Transportation Costs: $0.00 3. Temporary Total Disability (TTD) Wage Loss Average Weekly Wage ($): Number of Weeks Off Work: Total TTD Compensation: $0.00 4. Permanent Partial Disability (PPD) Assessment Body Part Injured: Arm at Shoulder (500 weeks) Arm at Elbow (450 weeks) Hand at Wrist (400 weeks) Leg at Knee (425 weeks) Foot at Ankle (250 weeks) Unscheduled Injury (Back/Torso – 1000 weeks) PPD Percentage (%): Total PPD Compensation: $0.00 Calculate Total Estimated Compensation: $0.00
