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Ant's Legal Expense Payment Reason Code Payee Start Date Through Date Issue Date Amount Paid John Doe 01/03/2013 01/03/2013 01/03/2013 $18,000.00 340 Attorney Doe 01/03/2013 01/03/2013 01/03/2013 $2,000.00 Recoveries Recovery Type PL E 500 Amount EMPLOYER / INSURED INFORMATION Employer FEIN xxxxx8765 Insured FEIN xxxxx8765 CONCURRENT EMPLOYER INFORMATION Contact Business Phone Wage SA M Name SROI-PY-R3 (1-14) Page 3 of 3 www.wcb.ny.gov.

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