GRANCELL, LEBOVITZ, STANDER,
REUBENS AND THOMAS
Attorneys at Law
A Professional Corporation
 
WORKERS' COMPENSATION FILE TRANSMITTAL

Claimant Information
Name:
Address:
City / State / Zip:
Date of Birth:
Social Sec. No:
Claimant Attorney Information
Name:
Firm:
Address:
City / State / Zip:
Phone/Fax: /
 
Employer Name: Employer Address: Carrier:
 
Date of Injury: Total T.D. Paid:
Claim No: Weekly Rate:
WCAB No: Total P.D. Paid:
Period Covered:   Total Medical Paid:
From:  To: 
 
  Apparent Reasons for Litigation
(Check Number of Reasons Below) Preparation for Hearing
 
1. Compensation not paid because: 1. Date and Time Hearing Set:  
   A. No employer's report
   A. No doctor's report 2. Has a wage statement been requested?:  
2. Disability:
   A. Temporary 3. Has the personel file been requested?:  
    B. Permanent
3. Medical Treatment 4. Do we have authority to do the following?
    A. Liability for Past     A. Set defense exams:  
    B. Need for Further     B. Set deposition:  
4. Injury AOE/COE     C. Order records:  
5. Statute of Limitations     D. Arrange investigator:  
6. Average Earnings
7. Occupation 5. New Case Law
8. Coverage for employer or this employee     A. Date claim form rec'd by employer:  
9. Employment or employer identity disputed     B. Date claim has been denied:  
10. Dependency or identity of dependents     C. Date application received:  
11. Subrogation potential, if any     D. Has a QME been chosen?
12. Other:

REMARKS BY CLAIMS EXAMINER:

Name of Company Sending File:  
Email Address of Sender:  
Date Sent:  
Claims Examiner:  
Address 1:  
Address 2:  

 

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