WORKERS' COMPENSATION LITIGATION TRANSMITTAL
WALL, McCORMICK & BAROLDI
A Professional Corporation
515 Cabrillo Park Drive, Suite 200
P.O. Box 1619
Santa Ana, CA 92702-1619
Phone: 714/547-7266
FAX: 714/547-3619
DATE OF HEARING
PREFERRED ATTORNEY, IF ANY:
DATE OF INJURY:
APPLICANT
EMPLOYER
WCAB NO.
CLAIM NO.
ENTIRE COVERAGE
OR P.S.I. PERIOD
TO
ENTIRE EMPLOYMENT
PERIOD
TO
AVERAGE
WEEKLY WAGES
$
WHY TD
TERMINATED
TD PAID
$
FROM
TO
TD RATE
TD PAID
$
FROM
TO
TD RATE
TD PAID
$
FROM
TO
TD RATE
PD PAID
$
FROM
TO
TOTAL PD ADV.
$
VRTD ATTY. FEES WITHHELD
SUGGESTED ISSUES: (PLEASE CHECK)
EMPLOYMENT
FURTHER MEDICAL CARE
JURISDICTION
OCCUPATION
SELF-PROCURED MEDICAL CARE
VOCATIONAL REHABILITATION
INJURY
EARNINGS
SUBROGATION
INSURANCE COVERAGE
DEPENDENCY
PERMANENT DISABILITY
STATUTE OF LIMIATIONS
TEMPORARY DISABILITY
APPORTIONMENT
MEDICAL PREPARATION:
ORIGINAL MEDICAL REPORTS ARE:
ATTACHED
FILED COPIES SERVED ON APPLICANT:
YES
NO
HAS FURTHER MEDICAL EXAM BEEN SCHEDULED:
YES
NO
IF YES: WITH WHOM:
WHEN:
MEDICAL/LEGAL LIENS PAID:
Remarks:
CARRIER
FROM
ADJUSTER
OF
ADMINISTRATOR
PHONE #