CLAIMS SPECIALIST
Name:
Address:
City/State/Zip:
Telephone:
Fax
Claim Number
Date Referred

Please attach all medicals with your referral.
DOCUMENTS ENCLOSED:
Copy of Medical Information
Copy of Employee’s Earnings

INJURED EMPLOYEE
Name :
Address:
City/State/Zip:
Telephone:
DOB:
DOH:
Weekly Wage $:
Weekly Benefit $ :
Social Security #:
Occupation:
Part of Body Affected:
Date of Injury:
Permanent & Stationary
Yes, Date: No
VRMA Start Date:
VRMA Rate: $

EMPLOYEE’S ATTORNEY
Name:
Address:
City/State/Zip:
Telephone:
Fax:
Selection made in agreement with applicant’s attorney: Yes No

DEFENSE ATTORNEY
Name:
Address:
City/State/Zip:
Telephone:
Fax:
Copy of reports to be mailed to defense attorney directly?
Yes No

PHYSICIAN
Name:
Address:
City/State/Zip:
Telephone:
Fax:
Is this physician to receive J.A.?
Yes No

EMPLOYER
Name:
Address:
City/State/Zip:
Telephone: