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 #