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A MESSAGE REGARDING COVID-19
File Transmittal Form
Submitter Email
Submitter First Name
Submitter Last Name
Claimant First Name
Claimant Last Name
Claimant Address
Claimant Date of Birth
Employer Name
Employer Address
Occupation
Claim Number
WCAB Number
Date of Injury
Policy Period Start
Policy Period End
Date of Knowledge
Date of Delay
Date of Denial
Medical Expenses
Temporary Disability
Temporary Disability Rate
Periods Covered
Wages
Wages
Wage Information Upload
Has Application Been filed?
Yes
No
Has DOR Been filed?
Yes
No
If DOR Been filed, do you have a hearing date?
Has a LC 4062.2 objection issued?
Yes
No
N/A
Is there a medical exam pending?
Doctor's name and Exam Type
Suggested Issues
Injury
Employment
Occupation
Coverage
Earnings
T.D.
P.D.Apptn
Past Med.
Future Med.
Subro
Statute of Limitations
Please mention any additional information that might be helpful
Remarks and Requests
Submit Claim
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