DATE ORDERED
WC PI CL
ORDER DUE DATE
   
Required
APPLICANT / PLAINTIFF INFORMATION
NAME:
A.K.A
DOB
SSN
DOI
CAN WE CONTACT THE APPLICANT IF WE EXPERIENCE TROUBLE LOCATING RECORDS ? (include phone number below)
PHONE
REQUESTING PARTY
ATTORNEY
STREET
CITY, ST, ZIP
EMAIL
DELIVER RECORDS TO
UPLOAD RECORDS
PARTIES TO THE CASE
WCAB CASE NO
REQUEST CLAIM FILE? 
CARRIER
CLAIM NO
ADJUSTER
STREET
CITY, ST, ZIP
PHONE FAX
REQUEST EMPLOYMENT FILE? 
EMPLOYER
STREET
CITY, ST, ZIP  
PHONE FAX
OPP ATTY
FIRM
STREET
CITY, ST, ZIP  
PHONE FAX
PLEASE OBTAIN RECORDS FROM THE FOLLOWING LOCATIONS
NAME
STREET
CITY, ST, ZIP  
PHONE
FAX
TYPE RECORDS
PREPARE SDT AUTHO ATTACHED 
COPY DATES
NAME
STREET
CITY, ST, ZIP  
PHONE
FAX
TYPE RECORDS
PREPARE SDT AUTHO ATTACHED 
COPY DATES
SPECIAL INSTRUCTIONS  
 
ADDITIONAL LOCATIONS
NAME
STREET
CITY, ST, ZIP  
PHONE
FAX
TYPE RECORDS
PREPARE SDT AUTHO ATTACHED 
COPY DATES
NAME
STREET
CITY, ST, ZIP  
PHONE
FAX
TYPE RECORDS
PREPARE SDT AUTHO ATTACHED 
COPY DATES
NAME
STREET
CITY, ST, ZIP  
PHONE
FAX
TYPE RECORDS
PREPARE SDT AUTHO ATTACHED 
COPY DATES
NAME
STREET
CITY, ST, ZIP  
PHONE
FAX
TYPE RECORDS
PREPARE SDT AUTHO ATTACHED 
COPY DATES
NAME
STREET
CITY, ST, ZIP  
PHONE
FAX
TYPE RECORDS
PREPARE SDT AUTHO ATTACHED 
COPY DATES
NAME
STREET
CITY, ST, ZIP  
PHONE
FAX
TYPE RECORDS
PREPARE SDT AUTHO ATTACHED 
COPY DATES
NAME
STREET
CITY, ST, ZIP  
PHONE
FAX
TYPE RECORDS
PREPARE SDT AUTHO ATTACHED 
COPY DATES
NAME
STREET
CITY, ST, ZIP  
PHONE
FAX
TYPE RECORDS
PREPARE SDT AUTHO ATTACHED 
COPY DATES
© Copyright 2010 - 2017 United Documents Imaging, Inc. All rights reserved