Legal Referrals Form

FROM:
 
File No:   
Policy No:   
Entire Period of Coverage:   
Accident Date:   
 
Claimant:   
Claimant Address:   
Date of Birth:   
 
Employer:   
 Individual Corporate   Co-Partnership   Joint Venture
 Other(Explain Below)
 
Employer Address:   
 
Temporary Paid:   
Rate:   
Periods Covered:   
Medical Paid:   
VRTD/RM Paid:   
Rate:   
Periods Covered:   
 
Permanent Paid:   
Rate:   
Periods Covered:   
Wage Basis:   
Occupation:   
 Permanent   Part-Time   Seasonal   Temporary   Casual
 Other(Explain Below)
 
Application Date:   
WCAB No:   
Hearing Date:   
Place:   
Judge:   
Date Claim Form Received:   
Date of Knowledge of Injury by Employer:   
Claimant"s Attorney:   
Attorney"s Address:   
Telephone:   
 
Suggested Issues
 Injury   Employment   Occupational   Coverage   Earnings
 Temporary Injury   Permanent Injury   Apportionment
 Past Medical   Future Medical Jurisdiction
 Dependency   Other (Explain Below)
 
Action Pending
 Medical Examination    Investigationt    Wage Statement
 Employer Statement    Other (Explain Below)
Medical Reports  Yes
Filed and Served?  No
(if no, please furnish original and two copies of all reports.)
Deposition  Yes
Authorized? No
 
*Name:   
*Email Address:   
Date:   
 
Remarks and Instructions: