Samuelsen, Gonzalez, Valenzuela & Brown, LLP

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Name and Address of Insured
Applicant Information	Individual Corporation Co-Partnership Joint Venture
Applicant's Name
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D.O.I (MM/DD/YYYY)
C.T.(MM/DD/YYYY)
Applicant's Attorney
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Policy#
Eff. Dates
Total Period of Coverage
Period of Employment
T.D. Periods Covered
Earnings $
Total Medical Paid $
Weekly Rate $
Total Indemnity Paid $
Advances on P.D. $
Apparent Reasons for Litigation	Temporary Disability Terminated by Doctor and Employee Disagrees Permanent Disability Prematurely Claimed Injury A.O.E. and/or C.O.E. Statue of Limitations Coverage for Employer or this Employee Dependency or Identity of Dependents Other
Legal Action Requested Preparation for Hearing	Set Depo Object PTP Rating Only File DOR State Panel or AME Other
Date of Hearing (MM/DD/YYYY)
WCAB Number
Place of Hearing
Date File Sent to Counsel (MM/DD/YYYY)
Have Medicals Been Filed and Served?	Yes No
Settlement Authority $
Demand $
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