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Name: John Doe
Customer Care number: 000000001
Payment date
April 28, 2022
Paid to
JOHN DOE
Payment method
EFT# 458980
Amount
$1,500.00
Claim number Description From To Amount
12345678 Wage loss Apr 21, 2022 Apr 28, 2022 $700.00
12345678 Wage loss Apr 13, 2022 Apr 20, 2022 $800.00
Claim number 1234567
Description Planning allowance
From Feb 16, 2021
To Feb 18, 2021
Amount $500.00
Claim number 1234567
Description Wage loss
From Feb 15, 2021
To Feb 28, 2021
Amount $500.00
Claim number 5495163
Description Planning allowance
From Feb 18, 2021
To Feb 20, 2021
Amount $448.43
Claim number 5495163
Description Planning allowance
From Feb 21, 2021
To Feb 24, 2021
Amount $0.00
Total $1,500.00
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