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PD RATING, 1997 SCHEDULE: SHOULDER LIMITATION OF MOTION

Date of birth:  
Date of injury:  4/1/1997 to 12/31/2004.
Which shoulder?      
Shoulder Abduction:injured: °   uninjured: °
Shoulder Forward Flexion:injured: °   uninjured: °
Fraction:
Standard Rating:%
Occupation by group number:
Or occupation by name:
Occupation description:
Percent industrial (apportionment):%
Average weekly earnings:$
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Age for calculation (DOI):
Final formula: 
Weekly Comp Rate:
$
Life Pension Weekly Rate:
$
Indemnity:
$
Weeks of Indemnity:
TTD Applies Rate: 

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c/o Business Insurance Holdings, Inc.
PO Box 1010
Greenwich, CT 06836
(805) 484-0333