Free Audit Referral Form - California

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AUDIT REFERRAL FORM

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Claims administrator / Company name

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Injured worker name

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Address

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Claim number

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City, state, ZIP

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Date of injury

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Date or period of violations

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Employer

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)