RATING REQUEST FORM

When you request a rating from us you may print out and use the form to the right or generate your own that has the same information.   Then mail or fax the form and report(s) to the address below.

You may also e-mail us the report(s) to the address below with a cover sheet of your choice that contains the same information as our rating request form.

If you prefer you can use our contact us tab above and we will mail, fax or email you the form.

This page is not copyrighted.

REQUEST FOR RATING

Your File #_____________________

Your Name_____________________

Company Name_________________

Street Address__________________

City,State, Zip__________________

Phone_________________________

Fax___________________________

Doctor's Name__________________

Report Date____________________

Injured's Name_________________

SSN#_________________________

Date of Injury__________________

Date of Birth___________________

Occupation_____________________

WCAB#_______________________

Type of Rating

(Circle all applicable): 

"AMA"

 "1997 Schedule"

"Both"

"Rush"