Employee Address

City

State Zip

Employer

Employer Address

City

State Zip

Date of Injury

Date of Hire

Date of Birth

Social Security No.

Claim Number(s)

WCAB Numbers

Occupation

Carrier

Policy Period

Venue

Part of Body

Date of Knowledge of Claimed Injury

Average Weekly Wage

MPN

(1) Injury AOE/COE

(2) Parts of Body Injured

(3) Period of Temporary Disability

(4) Earnings

(5) Permanent Disability

(6) Self-Procured Medical

(7) Future Medical

(8) Employment - Independent Contractor

(9) Coverage

(10) Occupation

(11) Statute of Limitations

(12) Vocational Rehabilitation

(13) Death and Dependency

(14) LC§132a

(15) Serious & Willful Against Employer

(16) Serious & Willful Against Employee

(17) Subrogation

(18) LC§5814 Penalty

(19) 90-Day Deadline Approaching

Examiner's Remarks

Examiner

Company

Date

Phone

Email

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URGENCY OR SPECIAL HANDLING INSTRUCTIONS

DOR Filed?

Date

Apperance Type

Date

Deposition scheduled or needed?

Medical Exam scheduled or needed?

With whom & when?

90-day deadline approaching?

Date

Original medical reports filed?

Copies served on applicant?

BENEFITS PAID (Omit Summary if attached)

Benefit Earnings

Benefit Earnings Per

Average Weekly Wage based on wage statement

Medical Treatment

Permanent Disability

Temporary Disability

Rate

Dates paid

POST 1-1-90 CASES ONLY

Claim form received?

Date

90th day to accept or deny is?

Denied within 90 days?

Date

If disabled for 90 days - QRR assigned?

Application Filed?

Date

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