IR EconLoss[NAR]

IR Economic Loss information. Required information is bold. (only if EconLoss is yes)

• IR EconLoss Claim

  • Is economic loss being claimed? (yes/no)

• IR EconLoss WageAmount

  • Amount of Last Annual Wages

• IR EconLoss WagesDate

  • Date last wages received

• IR EconLoss Full-Time

  • yes/no

• IR EconLoss Part-Time

  • yes/no

• IR EconLoss Retired

  • yes/no

• IR EconLoss PartiallyDisabled

  • yes/no

• IR EconLoss TotallyDisabled

  • yes/no

• IR EconLoss Deceased

  • yes/no