Free Audit Referral Form - California

File Size: 40.5 kB
Pages: 1
Date: June 22, 2006
File Format: PDF
State: California
Category: Workers Compensation
Author: Rebecca G. Lawas
Word Count: 139 Words, 1,343 Characters
Page Size: Letter (8 1/2" x 11")

Download Audit Referral Form ( 40.5 kB)

Preview Audit Referral Form



Claims administrator / Company name

Injured worker name


Claim number

City, state, ZIP

Date of injury

Date or period of violations


SPECIFIC DETAILS OF COMPLAINT List the nature of the complaint, being as specific as possible. For example, late payments of temporary or permanent disability (the number of late payments, if known), failure to pay temporary or permanent disability, vocational rehabilitation maintenance allowance, or 10% selfimposed penalties for late payments (indicate the periods not paid, if known), failure to provide vocational rehabilitation services when indicated, failure to pay or object to medical treatment or medical-legal bills, failure to investigate a claim, unsupported denial of liability for a claim, et al. Please attach copies of supporting documentation, if available.

_____________________________________ Complainant (name & title) _____________________________________ Address, city, state, ZIP

________________________ Date

Form DWC-AU-906 (Rev 06/06)