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Client Address

Insurance

FILE TRANSMITTAL - WCAB CASE NO.

CLAIM NO.

POLICY OR CERT. NO.

POLICY PERIOD

ACCIDENT DATE

CLAIMANT

OCCUPATION

DATE OF BIRTH

EMPLOYER

EMPLOYER’S ADDRESS

HEARING

DATE:

TIME:

PLACE:

TYPE:

TEMPORARY PAID

RATE

PERIODS COVERED

PERMANENT PAID

RATE

PERIODS COVERED

EARNINGS

SUGGESTED ISSUES

Injury

Employment

Occupation

Coverage

Earnings

TD

PD

Apportionment

Past Medical

Future Medical

Stat of Limitation

Jurisdiction

Dependency

Rehabilitation

Other: Explain

MEDICAL EVALUATIONS

Please set

Already set with

Dr.

On

CLAIM FORM FILED ON:

DENIAL DATE:

DENIAL ISSUED: YES

DENIAL ISSUED: NO

IF YES, DATE:

REMARKS AND INSTRUCTIONS:

EXAMINER:

PHONE:

DATED:

SIGNED:

EMAIL:

Refer a Claim

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