Type of benefit requested: 10 = No lost time.Lost Time
20 = Med onlyMedical Only
21 = Temorary Parial Temporary Partial Disability
25 = Controvered Med onlyOnly
30 = Volunteer
40 = Death / no daysNo Days
50 = Salary Continued
60 = Salary by Mileage 70 = Minimum Weekly Rate | 