Non-Prejudicial AgreementNon-Prejudicial Agreement • June 24th, 2014
Employee Information Employer Information SSN or ID FEIN Name Business Name Address Address City, State Zip City, State Zip Date of Birth Phone Insurer Information Claim Administrator Information (Adjusting Company) FEIN FEIN Business Name Business Name Address Address City, State Zip City, State Zip Phone Phone Injury Information Date of Injury Place where injury occurred Injured body part & nature of injury Rate Information Employee's Marital Status Single Married Number of Dependents (children & nonworking spouse) Number of Exemptions (self, spouse & children) Total Average Weekly Wage Spendable Base Wage Base Compensation Rate Weekly Dependency Rate Total Weekly Rate Disability Information First Payment Issue Date First Date of Disability Temporary Total Start Date Temporary Partial Start Date Permanent Total Start Date Death Benefits Start Date Date of Death Death Benefits Paid to Other information Does the employee have other employers? Yes No Attach a completed wage statement f
