Date of Injury
Date of Hire
Date of Birth
Social Security No.
Part of Body
Date of Knowledge of Claimed Injury
Average Weekly Wage
(1) Injury AOE/COE
(2) Parts of Body Injured
(3) Period of Temporary Disability
(5) Permanent Disability
(6) Self-Procured Medical
(7) Future Medical
(8) Employment - Independent Contractor
(11) Statute of Limitations
(12) Vocational Rehabilitation
(13) Death and Dependency
(15) Serious & Willful Against Employer
(16) Serious & Willful Against Employee
(18) LC§5814 Penalty
(19) 90-Day Deadline Approaching
For your added convinience, you may include up to three separate attachments with your E-Litigation Form submittal.
Upload No. 1
Deposition scheduled or needed?
Medical Exam scheduled or needed?
With whom & when?
90-day deadline approaching?
Original medical reports filed?
Copies served on applicant?
BENEFITS PAID (Omit Summary if attached)
Benefit Earnings Per
Average Weekly Wage based on wage statement
POST 1-1-90 CASES ONLY
Claim form received?
90th day to accept or deny is?
Denied within 90 days?
If disabled for 90 days - QRR assigned?