| Subject Information: |
| Name: |
JOHN SMITH |
| Date of Birth: |
01/12/64 |
| Address: |
480 W. SQUARE AVE.,
MIAMI, FL |
| SSN: |
123-45-XXXX |
| Sex: |
MALE |
| Age: |
39 |
| State: |
FOROLIDA |
| Number: |
851863 |
| Injury Date: |
10/24/1990 |
| Returned to Work: |
03/18/1991 |
| CMP Paid: |
$156 |
| MED Paid: |
$804 |
| Disablement: |
Temporary Total |
| Injury Type: |
MISCELLANEOUS OR MULTIPLE |
| Injury Location: |
Upper Arm |
| Injury Source: |
USING TOOL OR MACHINE |
| Employer Name: |
ABC Company, LLC |
| Date Hired: |
10/31/1983 |
This is a sample report of the Workers Compensation Records. |