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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:
Send
