7555 North Del Mar  ~  Suite 206  ~  Fresno, CA 93711
Phone: 559-439-2612  ~  Fax: 559-439-4960
E-Mail: info@alabart.com
 

Litigation Referral Sheet

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Claim No. 
Date of Injury 
WCAB No. 
Applicant's Name 
Name of Employer 

 Individual
 Corporation		  Partnership
 Joint Venture

Policy Period: 


Apparent Reasons for Litigation

Employment or employer identity disputed
Occupation
Injury AOE/COE
Coverage for employer or this employee
 
Medical Treatment
   Liability for past
   Need for further
 
Average Earnings
Temporary Disablility
Permanent Disability
Apportionment
Dependency or I.D. of dependents
Statute of Limitations or Notice
Rehabilitation
Benefit Overpayment
Other

Total T.D. Paid 
Weekly Rate 
Periods Covered 
Amount of T.D. Overpayment 
Period 
P.D. Paid 
Periods Covered 
V.R.M.A. Paid 
Periods Covered 
Total Medical Paid 
Attorney Fee Withheld 


Preparation for Hearing

Date Hearing Set 
Place of Hearing 
Has medical been filed with WCAB and served?   Yes    No
Have you arranged for further medical examination?   Yes    No
Name of doctor 
Date of examination 
What medical/legal costs have been paid? 
Liens filed 

Remarks by Claims Person
Name of Company Sending File 

Claims Person 

 

 

 

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