GLSRT Workers' Compensation File Transmittal Form

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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