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Workers' Compensation File Transmittal
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Referring Administrator/Carrier
Referrer Company Name
Referrer Name
*
First
Last
Referrer Address
*
Street Address
Address Line 2
City
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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
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Antigua and Barbuda
Argentina
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Australia
Austria
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Burkina Faso
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Cameroon
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Cape Verde
Cayman Islands
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Chad
Chile
China
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Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
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Dominican Republic
East Timor
Ecuador
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Equatorial Guinea
Eritrea
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Ethiopia
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Finland
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French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
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Greenland
Grenada
Guam
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Guinea-Bissau
Guyana
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Mozambique
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Namibia
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Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Northern Mariana Islands
Norway
Oman
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Palestine, State of
Panama
Papua New Guinea
Paraguay
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Poland
Portugal
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Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Saint Martin
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
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
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Greenland
Grenada
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Saint Martin
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
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
*
Employment
Coverage
Injury AOE/COE
Statute of Limitations
Occupation
Average Earnings
Entitlement to Temporary Disability
Entitlement to Permanent Disability
Medical Treatment
Panel QME Needed
132a Defense
Serious and Willful Misconduct Defense
Dependency
Subrogation
Other
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
AM
PM
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
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