Stockwell, Harris, Woolverton and Muehl

*Required

Claimant Name*

Master Claim Number(s)*

Policy or Certificate Number*

Policy Period*

Earnings*

Employer Contact*

WCAB Number(s)*

Corresponding Date(s) of Injury*

If so, please insert WCAB number, date, time, place, and type of hearing here:

Benefits Paid (TD, PD, Medical):

Litigation Referral Notes:

Application, claim form, employers report
Complete medical file
Copies of all notices sent to applicant (MPN notification, benefit notices, delay, denial, etc.)
Copies of all payment records
Copies of all utilization review requests and responses
Wage statement
All pertinent correspondence
Copies of subpoenaed records
Investigation reports, films and/or statements

REMARKS AND INSTRUCTIONS:

Date:

Your Name

Phone Number

Fax Number

E-Mail Address

Mailing Address

Idenity of Referring TPA

Identity of Insurer

Legal Referral Form