Please Complete and Include with Referral

Walk-Through Checklist (Please Complete and Include with Referral)

____ Applicant Name / Claim #______

____ Fully Executed Compromise and Release or Stipulation with Request for AWARD. (If you are having difficulty getting applicant’s signature, we may be able to aid in getting this accomplished on a case-by- case basis.)

____ Copies of ENDING TD & ENDING PD summary Benefit Notices IF SETTLEMENT IS BASED ON THE TREATING PHYSICIAN, IT IS IMPERATIVE THAT WE HAVE THE PD NOTICE INDICATING THAT YOU ACCEPT THE FINDINGS OF THE TREATING PHYSICIAN AND ADVISES THE APPLICANT OF THEIR QME RIGHTS – WITH PROOF OF SERVICE OF NOTICE, IF AVAILABLE.

____ QME WAIVER

____ Benefit Printout of indemnity paid (PD and TTD), that shows total medical paid.

____ Wage Statement if benefits paid at less than Maximum. (INCLUDE COPY OF TAPE CALCULATIONS AND ADDITIONAL EXPLANATION OF SEASONAL OR IRREGULAR WAGES).

____ DEU Rating or Private Rating

____ Known liens, including appended documentation.

____ Settlement authority for known liens.

____ CASES WITH DOI PRIOR TO 2013, Notice of Offer of Regular or Alternative Work if you are taking a 15% reduction on the PD. Please include Proof of Service that accompanied Notice to applicant.

____ Application for adjudication and/or disclosure statements/substitution of attorneys (if applicable). If applicant was represented and now is pro per, we need substitution of attorneys prior to proceeding with any settlement.

____ Treating physician’s MMI (P&S) report and Panel QME or AME report (if applicable), MRI reports, Surgical reports.

*** We do not need the entire medical file, or ALL TD & PD letters (just the most recent one summarizing the benefits paid.

Adjuster Name, Email, Phone #: ______

Comments / Special Handling: ______

Resolution Partners Micro & Macro, LLC I 20687-2 Amar Rd., #824 I Walnut, CA 91789 I O (626) 839-4475 I F (626) 332-8033 ______

Over 15 years of California Workers’ Compensation Experience. We appear before ALL Northern California WCAB Venues! Defense Lien Representation, Expert Witness Bill Review, Defense Hearing Representation, Walk-Through Procedures, Adequacy Hearings, Settlement/Litigation Analysis, Expedited Settlement Procedures/Special Circumstance and Hardship resolutions.