Full file referral
I am referring this file to
Third Party Administrator
Date(s) of Injury
WCAB Case Number(s)
Date of Birth
Average Weekly Wage
Temporary Disability Rate
Permanent Disability Rate
Future Medical Treatment
Statute of Limitations
Is there a decision date?
If yes, please list the decision date(s) and date(s) of injury
Is there an AME/QME?
If yes, please list the name(s) of doctor(s)
If yes, please list the evaluations scheduled (if applicable)
Are there any Hearings on calendar?
If yes, please list the Hearing information
Are there any Depositions scheduled?
If yes, please list the Deposition information
If no, would you like us to schedule the applicant's Deposition?
If there is any additional information you would like us to include, please provide below. Also, if there is any immediate action you would like us to take, please indicate below.
**If referral is for walkthrough purposes only, please see the walkthrough checklist for documents to incude with the referral.