Dietz, Gilmor & Associates

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E-Refer

This is an automated referral script.  Please complete all applicable fields, review your entries and when ready, please click the submit button.

General E-Referral Information:
Claimant:
Date(s) of Injury:
Insured:
WCAB No(s).:
Claim Number:
Insurance Company:
Policy No.:
Coverage:
Hearing Scheduled:Yes

No

Date:
Time:
Board:
Deposition Authorized:YesNo
Date of Employer Knowledge:
Date DWC-1 Given to Employee:
Date DWC-1 Returned to Employer:
Total Benefits Paid to Date:
Medical Paid:
Temporary Disability:Total:
Rate:
Period of Payments: to
Issues:
Insurance Coverage
Employment
Injury AOE/COE
Parts of Body
Earnings
Rate (TD/PD)
Temporary Disability
Permanent Disability
Apportionment
Fraud
Medical/Legal Liens
Other Liens
Further Treatment
Self-Procured Medical Treatment
Death Claim
Dependency
Statute of Limitations
Prejudiced by Lack of Notice
Subrogration
Third Party Recovery Credit
Comments:
Submitted By:

Date:

Contact Number:()- ext.

Email: