Referrals

Referring Administrator/Carrier

Referrer Company Name

Referrer Name*

First Last

Referrer Address*

Street Address Address Line 2 City State ZIP Code

Referrer Phone Number*

Referrer Email*

Referral Date*

Claim Number*

If you have more than one claim number, separate them with commas

Comments/Details of Assignment

Claimant Info

Claimant Name*

First Last

Claimant's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Claimant's Date of Birth

Claimant's Social Security Number*

Employer*

Employer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Carrier*

Date of Hire

Date of Injury*

Average Weekly Wages

TTD Rate

Total TTD Paid

From

To

Add another time period? 1

Yes

From

To

Add another time period? 2

Yes

From

To

PD Rate

Total PD Paid

From

To

Add another time period? 3

Yes

From

To

Add another time period? 4

Yes

From

To

Total Medical Paid

Issues for Litigation Assignment*

Check all that apply.

Please Explain

Hearing

Is there a scheduled hearing?*

Yes
No
I don't know

WCAB Location of Hearing

Date of Hearing

Time of Hearing

: HH

MM

Investigation

Has a wage statement been requested?

Yes
No

Has the personnel file been requested?

Yes
No

Do we have authority to do the following?*

Check all that apply.

Schedule deposition
Subpoena records
Request Panel QME
Arrange employer level investigation
Arrange surveillance investigation
Other

Please Explain

Date Claim Form received by employer

Has claim been denied?*

Yes
No

Date of denial

Is the applicant represented by an attorney/law firm?*

Yes
No

Name of Attorney/Law Firm

Address of Attorney/Law Firm

Street Address Address Line 2 City State ZIP Code

Phone Number of Attorney/Law Firm

Date Notice of Representation received

Has Application been filed?

Yes
No

WCAB/ADJ Number

Date Application received

What date did you receive the WCAB Notice of Application Filed?

Does employer have an MPN?

Yes
No

MPN Info

Primary Treating Physician

Has a QME been chosen?

Yes
No

QME Info

If you have more than one QME, separate them with commas

Workers' Compensation File Transmittal

Referring Administrator/Carrier

Claimant Info

Hearing

Investigation