Listen to Mark H. Barber's Workers' Compensation radio interview...

Designed by Goldfish Consulting

Employee/Claimant*

Claimant's Address
City
State
Zip
Employer*
Employer Address
City
State
Zip
Date(s) of Injury
Date of Birth
Social Security Number
   
Claim Number(s)
   
WCAB Number
Occupation
   
Insurance Carrier
Policy Period(s)
   














     
   
Appearance Set
     






Date    
Discovery Deadline Date    
 




     
   
Benefit Printout to follow    
TD Paid?      
  Date
     
  Weekly Rate
     
     
  Date
     
  Weekly Rate
     
       
   
Claims Handler*
Company
   
Date
Phone Number
   
e-mail*
     
Comments/Special Handling Instructions
*required