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<eForms>
	<Header>
		<APIHeader>
			<SubmitterClientId>testid</SubmitterClientId>
			<SenderPOI>R999999</SenderPOI>
			<SubmitDate>2024-04-04</SubmitDate>
		</APIHeader>
	</Header>
	<Events>
		<EventCode code="RFA-1LC">
			<TransactionSequenceNumber>12923432934</TransactionSequenceNumber>
			<WCBCaseID>12345678</WCBCaseID>
			<DateOfInjury>
				<DoiMonth>03</DoiMonth>
				<DoiDay>18</DoiDay>
				<DoiYear>1991</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>CVW</ReasonCode>
					<ReasonCodeCategory>C</ReasonCodeCategory>
					<PaymentStatus>PN</PaymentStatus>
					<AwardPeriods>
						<AwardPeriod index="1">
							<DisabilityPercentage>23</DisabilityPercentage>
							<DisabilityFromDate>2021-06-01</DisabilityFromDate>
							<DisabilityToDate>2021-06-30</DisabilityToDate>
						</AwardPeriod>
						<AwardPeriod index="2">
							<DisabilityPercentage>5</DisabilityPercentage>
							<DisabilityFromDate>2021-10-10</DisabilityFromDate>
							<DisabilityToDate>2021-11-11</DisabilityToDate>
						</AwardPeriod>
					</AwardPeriods>
					<DisabilityContinuingPaymentIndicator>N</DisabilityContinuingPaymentIndicator>
					<AdditionalInformation>Adding some additional info here.</AdditionalInformation>
					<ExpeditedHearingRequested>N</ExpeditedHearingRequested>
				</Reason>
			</Reasons>
			<SupportingDocuments>
				<UploadedDocuments>
					<UploadedDocument index="1">
						<UploadFormId>MED-NARR</UploadFormId>
						<UploadDocumentFormName>MED-NARR - Medical Narrative</UploadDocumentFormName>
						<UploadFileName>mednar.pdf</UploadFileName>
						<UploadFileType>PDF</UploadFileType>
						<UploadHealthCareProviderName>Dr Joe Smith</UploadHealthCareProviderName>
						<UploadServiceDate>2021-07-15</UploadServiceDate>
						<UploadFileSize>1287</UploadFileSize>
						<UploadDocumentDescription>Notes on case</UploadDocumentDescription>
						<UploadSupportingDocumentImage>98sd9f990d9fds9ds9f90ds90</UploadSupportingDocumentImage>
					</UploadedDocument>
				</UploadedDocuments>
				<ReferencedDocuments>
					<ReferencedDocument index="1">
						<ReferenceDocumentId>8373737336363</ReferenceDocumentId>
						<ReferenceFormId>PAYROLL</ReferenceFormId>
						<ReferenceDocumentReceivedDate>2021-07-31</ReferenceDocumentReceivedDate>
					</ReferencedDocument>
				</ReferencedDocuments>
			</SupportingDocuments>
			<AdditionalProposedFinding>
				<AdditionalProposedFindingANCR>Y</AdditionalProposedFindingANCR>
				<AdditionalProposedFindingBodyParts>
					<AdditionalProposedFindingBodyPart index="1">
						<AdditionalProposedFindingBodyPartCode>43</AdditionalProposedFindingBodyPartCode>
					</AdditionalProposedFindingBodyPart>
					<AdditionalProposedFindingBodyPart index="2">
						<AdditionalProposedFindingBodyPartCode>57</AdditionalProposedFindingBodyPartCode>
						<AdditionalProposedFindingBodyPartLocationCode>L</AdditionalProposedFindingBodyPartLocationCode>
						<AdditionalProposedFindingBodyPartFingersToesCode>T4</AdditionalProposedFindingBodyPartFingersToesCode>
					</AdditionalProposedFindingBodyPart>
				</AdditionalProposedFindingBodyParts>
				<AdditionalProposedFindingAWW>Y</AdditionalProposedFindingAWW>
				<EstablishAWWResultInAdjustmentIndicator>N</EstablishAWWResultInAdjustmentIndicator>
				<EstablishAWWPrimaryEmployerDollarAmount>24.23</EstablishAWWPrimaryEmployerDollarAmount>
				<EstablishAWWCalculationMethod>FRSR</EstablishAWWCalculationMethod>
				<EstablishAWWCalculationMethodOther>Other description goes here</EstablishAWWCalculationMethodOther>
				<EstablishAWWConcurrentEmployment>N</EstablishAWWConcurrentEmployment>

				<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>TTD</AwardPeriodDesignationCode>
								<AwardPeriodDisabilityPercentage>22</AwardPeriodDisabilityPercentage>
								<AwardPeriodReimburseEmployerIndicator>Y</AwardPeriodReimburseEmployerIndicator>
								<AwardPeriodAwardIndicator>N</AwardPeriodAwardIndicator>								
							</AwardPeriodDesignation>
						</AwardPeriodDesignations>
					</ALWBAwardPeriod>
					<ALWBAwardPeriod index="2">
						<AwardPeriodFromDate>2022-12-30</AwardPeriodFromDate>
						<AwardPeriodToDate>2023-01-15</AwardPeriodToDate>
						<AwardPeriodDesignations>
							<AwardPeriodDesignation index="1">
								<AwardPeriodDesignationCode>RE</AwardPeriodDesignationCode>
								<AwardPeriodRequiredRate>1200</AwardPeriodRequiredRate>
								<AwardPeriodAwardIndicator>Y</AwardPeriodAwardIndicator>
							</AwardPeriodDesignation>
							<AwardPeriodDesignation index="2">
								<AwardPeriodDesignationCode>HIA</AwardPeriodDesignationCode>
								<AwardPeriodAwardIndicator>N</AwardPeriodAwardIndicator>
							</AwardPeriodDesignation>
						</AwardPeriodDesignations>
					</ALWBAwardPeriod>
				</AdditionalProposedFindingAwardPeriods>

				<AdditionalProposedFindingAttorneyFeeReq>Y</AdditionalProposedFindingAttorneyFeeReq>
				
			</AdditionalProposedFinding>
			<Certification>
				<CertificationCode>NORS</CertificationCode>
				<AttemptedCertificationContacts>
					<AttemptedContact index="1">
						<PersonContactedFirstName>Farmer</PersonContactedFirstName>
						<PersonContactedLastName>Johns</PersonContactedLastName>
						<PersonContactedOrganizationName>Pioneer</PersonContactedOrganizationName>
						<PersonContactedDate>2023-06-01</PersonContactedDate>
					</AttemptedContact>
					<AttemptedContact index="2">
						<PersonContactedNameUnknown>Y</PersonContactedNameUnknown>
						<PersonContactedOrganizationName>Pioneer</PersonContactedOrganizationName>
						<PersonContactedDate>2023-06-02</PersonContactedDate>
						<PersonContactedPhoneNumber>5185552323</PersonContactedPhoneNumber>
						<PersonContactedEmail>my.test@second.test.com</PersonContactedEmail>
					</AttemptedContact>
				</AttemptedCertificationContacts>
			</Certification>
		</EventCode>
	</Events>
</eForms>
