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Defending
employers, insurance carriers and third party administrators
since 1962
Rating referral
Please provide the following information:
Name and Address of Insured
Individual
Corporation
Co-Partnership
Joint Venture
Applicant Information
Applicant's Name
Applicant's Address
D.O.I
C.T.
Applicant's Attorney
Phone
Address
Claim Number
Gender
Male
Female
Occupation
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
Set Depo
Object PTP
Rating Only
File DOR
State Panel or AME
Other
Preparation for Hearing
Date of Hearing
WCAB Number
Eff. Dates
Date File Sent to Counsel
Have Medicals Been Filed and Served?
Yes
No
Settlement Authority $
Demand $
Special Instructions and Remarks
Contact
Client
Phone
Email
Fax
Address
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