Refer A Claim COX & ASSOCIATES P.C. Workers Compensation Defense and Subrogation In Northern California Client Address Insurance FILE TRANSMITTAL - WCAB CASE NO. CLAIM NO. POLICY/CERT. NO. POLICY PERIOD ACCIDENT DATE CLAIMANT OCCUPATION DATE OF BIRTH EMPLOYER EMPLOYER'S ADDRESS HEARING DATE TIME PLACE TYPE TEMPORARY PAID RATE PERIODS COVERED PERMANENT PAID RATE PERIODS COVERED EARNINGS SUGGESTED ISSUES Injury Emplyment Occupation Coverage Earnings SUGGESTED ISSUES TD PD Apportionment Past Medical Future Medical SUGGESTED ISSUES Stat of Limitation Jurisdiction Dependency Rehabilitation Other: ExplainMEDICAL EVALUATIONSPlease set Already set with Dr. On CLAIM FORM FILED ON DENIAL DATE DENIAL ISSUED YES NO IF YES, DATE REMARKS AND INSTRUCTIONSEXAMINER PHONE DATED SIGNED EMAIL CAPTCHA Δ
