EMPLOYEE (CLAIMANT) CLAIMS ADMINISTRATOR Employee's Name Street Address    Telephone Number Social Security #      Date of Birth   Date of Injury        Occupation                            Wages                     TD Rate     HOUR DAY WEEK MONTH YEAR    Language     Eligibility Date   Type of Injury      Administrator's Name Company Name Street Address CA Telephone Number Fax Number    Claim Number TREATING PHYSICIAN EMPLOYER Facility Name Physician's Name Street Address CA Telephone Number Fax Number      Employer's Name Street Address CA Contact Person Telephone Number Fax Number    APPLICANT'S ATTORNEY DEFENSE ATTORNEY Attorney's Name Law Firm's Name Street Address CA Telephone Number Fax Number    Authorize Regain As A.V.E. Attorney's Name Law Firm's Name Street Address CA Telephone Number Fax Number    SERVICES AUTHORIZED 90 DAY CONTACT (IN PERSON) 90 DAY CONTACT (TELEPHONIC)   MEDICAL MANAGEMENT  JOB ANALYSIS VOCATIONAL SERVICES            ESSENTIAL JOB FUNCTIONS          ERGONOMIC ASSESSMENT LONG TERM DISABILITY            LTD. MED. EVAL. (2-PT CONTACT)  LTD. MED. EVAL. (3-PT CONTACT)  Other:  TYPE OF REFERRAL WORKER'S COMPENSATION LONG TERM DISABILITY SPOUSAL SUPPORT PERSONAL INJURY  Other:  Notes/Special Instructions