Workers' Compensation Records Order

ship_attention_to_

ship_firm_name_

ship_address_

ship_city_

ship_state State Alabama Alaska American Samoa Arizona Arkansas Armed Forces Africa Armed Forces Americas (except Canada) Armed Forces Canada Armed Forces Europe Armed Forces Middle East Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

ship_zip_

ship_phone_

ship_fax_

ship_email_

Number and Types of Records

ship_cd_qty_ CD Qty 1 2 3 4 5 6 7 8 9 10

ship_paper_qty_ Paper Qty 1 2 3 4 5 6 7 8 9 10

Download Only (DO NOT send Paper or CD)

download_only_

Summarize over 50 pages

summarize_

Index Records (list page number, name of provider and brief description only.)

index_records_

ship_instructions_

party_address_

party_city_

party_state_ State Alabama Alaska American Samoa Arizona Arkansas Armed Forces Africa Armed Forces Americas (except Canada) Armed Forces Canada Armed Forces Europe Armed Forces Middle East Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

party_zip_

party_phone_

party_email_

party_represent_ - Representing - Defendant Respondent Plaintiff Applicant Petitioner Other

Send notice to Consumer:

Yes notify_customer_

Medical

medical

Bills

bills

X-ray Films

x_ray_films

Psychiatric (Release Needed)

psychiatric

Financial

financial

Schools

schools

Employment

employment

Insurance

insurance

Others

other

witness_firm_name_

witness_attention_to_

witness_address_

witness_city_

witness_state_ State Alabama Alaska American Samoa Arizona Arkansas Armed Forces Africa Armed Forces Americas (except Canada) Armed Forces Canada Armed Forces Europe Armed Forces Middle East Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

witness_zip_

witness_phone_

witness_fax_

witness_instructions_