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	<Header>
		<APIHeader>
			<SubmitterClientId>testing</SubmitterClientId>
			<SenderPOI>R999999</SenderPOI>
			<SubmitDate>2024-04-04</SubmitDate>
		</APIHeader>
	</Header>
	<Events>
		<EventCode code="RFA-1LC">
			<TransactionSequenceNumber>12923432934</TransactionSequenceNumber>
			<WCBCaseID>12345678</WCBCaseID>
			<DateOfInjury>
				<DoiMonth>08</DoiMonth>
				<DoiDay>17</DoiDay>
				<DoiYear>1990</DoiYear>
			</DateOfInjury>
			<AttestationConfirmationCode>Y</AttestationConfirmationCode>
			<AttorneyLicensedRepFirstName>Joe</AttorneyLicensedRepFirstName>
			<AttorneyLicensedRepLastName>Representative</AttorneyLicensedRepLastName>
			<AttorneyLicensedRepRnum>R999999</AttorneyLicensedRepRnum>
			<AttorneyLicensedRepPhone>8005551212</AttorneyLicensedRepPhone>
			<AttorneyLicensedRepPhoneExt>24</AttorneyLicensedRepPhoneExt>
			<Reasons>
				<Reason index="1">
					<ReasonCode>CAW</ReasonCode>
					<ReasonCodeCategory>C</ReasonCodeCategory>
					<AwardPeriods>
						<AwardPeriod index="1">
							<DisabilityPercentage>33.99</DisabilityPercentage>
							<DisabilityFromDate>2020-01-01</DisabilityFromDate>
							<DisabilityToDate>2020-02-29</DisabilityToDate>
							<IntermittentLostTimeIndicator>Y</IntermittentLostTimeIndicator>
							<IntermittentLostTimeDays>50</IntermittentLostTimeDays>
						</AwardPeriod>
						<AwardPeriod index="2">
							<DisabilityPercentage>5</DisabilityPercentage>
							<DisabilityFromDate>2021-10-10</DisabilityFromDate>
							<DisabilityToDate>2021-11-11</DisabilityToDate>
							<IntermittentLostTimeIndicator>N</IntermittentLostTimeIndicator>
						</AwardPeriod>
					</AwardPeriods>
					<DisabilityContinuingPaymentIndicator>N</DisabilityContinuingPaymentIndicator>
					<AWWForPrimaryEmployer>35.22</AWWForPrimaryEmployer>
					<AWWCalculationMethod>S200</AWWCalculationMethod>
					<AWWCalculationOther>Other calculation method info here</AWWCalculationOther>
					<AdditionalInformation>Add general additional info here.</AdditionalInformation>
				</Reason>
			</Reasons>
			<SupportingDocuments>
				<ReferencedDocuments>
					<ReferencedDocument index="1">
						<ReferenceDocumentId>44345555544</ReferenceDocumentId>
						<ReferenceFormId>CORR</ReferenceFormId>
						<ReferenceDocumentReceivedDate>2020-09-23</ReferenceDocumentReceivedDate>
					</ReferencedDocument>
				</ReferencedDocuments>
			</SupportingDocuments>
			<AdditionalProposedFinding>
				<AdditionalProposedFindingANCR>Y</AdditionalProposedFindingANCR>
				<AdditionalProposedFindingBodyParts>
					<AdditionalProposedFindingBodyPart index="1">
						<AdditionalProposedFindingBodyPartCode>17</AdditionalProposedFindingBodyPartCode>
					</AdditionalProposedFindingBodyPart>
					<AdditionalProposedFindingBodyPart index="2">
						<AdditionalProposedFindingBodyPartCode>36</AdditionalProposedFindingBodyPartCode>
						<AdditionalProposedFindingBodyPartLocationCode>R</AdditionalProposedFindingBodyPartLocationCode>
						<AdditionalProposedFindingBodyPartFingersToesCode>F1</AdditionalProposedFindingBodyPartFingersToesCode>
					</AdditionalProposedFindingBodyPart>
				</AdditionalProposedFindingBodyParts>
				<AdditionalProposedFindingBodyPartAdditionalText>Carpal tunnel syndrome</AdditionalProposedFindingBodyPartAdditionalText>				
				<AdditionalProposedFindingAwardLostWageBen>Y</AdditionalProposedFindingAwardLostWageBen>
				<ALWBContinuingPaymentIndicator>N</ALWBContinuingPaymentIndicator>
				<AdditionalProposedFindingAwardPeriods>
					<ALWBAwardPeriod index="1">
						<AwardPeriodFromDate>2022-12-12</AwardPeriodFromDate>
						<AwardPeriodToDate>2022-12-24</AwardPeriodToDate>
						<AwardPeriodFreeText>Extra free text</AwardPeriodFreeText>
						<AwardPeriodDesignations>
							<AwardPeriodDesignation index="1">
								<AwardPeriodDesignationCode>ILT</AwardPeriodDesignationCode>
								<AwardPeriodDisabilityPercentage>22</AwardPeriodDisabilityPercentage>
								<AwardPeriodReimburseEmployerIndicator>Y</AwardPeriodReimburseEmployerIndicator>
								<AwardPeriodAwardIndicator>N</AwardPeriodAwardIndicator>
								<AwardPeriodRequiredNumberofDays>2</AwardPeriodRequiredNumberofDays>								
							</AwardPeriodDesignation>
						</AwardPeriodDesignations>
					</ALWBAwardPeriod>
					<ALWBAwardPeriod index="2">
						<AwardPeriodFromDate>2022-12-30</AwardPeriodFromDate>
						<AwardPeriodToDate>2023-01-15</AwardPeriodToDate>
						<AwardPeriodFreeText>Add more details here</AwardPeriodFreeText>
						<AwardPeriodDesignations>
							<AwardPeriodDesignation index="1">
								<AwardPeriodDesignationCode>PPD</AwardPeriodDesignationCode>
								<AwardPeriodRequiredRate>120</AwardPeriodRequiredRate>								
							</AwardPeriodDesignation>
							<AwardPeriodDesignation index="2">
								<AwardPeriodDesignationCode>HIA</AwardPeriodDesignationCode>
								<AwardPeriodAwardIndicator>Y</AwardPeriodAwardIndicator>								
							</AwardPeriodDesignation>
						</AwardPeriodDesignations>
					</ALWBAwardPeriod>
				</AdditionalProposedFindingAwardPeriods>
				<AdditionalProposedFindingAttorneyFeeReq>Y</AdditionalProposedFindingAttorneyFeeReq>
			</AdditionalProposedFinding>
			<Certification>
				<CertificationCode>NORS</CertificationCode>
				<AttemptedCertificationContacts>
					<AttemptedContact index="1">
						<PersonContactedFirstName>Jennifer</PersonContactedFirstName>
						<PersonContactedLastName>Smith</PersonContactedLastName>
						<PersonContactedOrganizationName>Acme Test LLC</PersonContactedOrganizationName>
						<PersonContactedDate>2023-06-23</PersonContactedDate>
					</AttemptedContact>
				</AttemptedCertificationContacts>
			</Certification>			
		</EventCode>
	</Events>
</eForms>
