Fillable CARRIER BILLING INFORMATION CUSTOMER INFORMATION

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CARRIER BILLING INFORMATION CUSTOMER INFORMATION

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File type: PDF

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CUSTOMER INFORMATION
Date Ordered: Rush:
Date Due:
Your Firm:
Atty/Adj Name: SB#:
Address:
City: State: Zip:
Phone: Fax:
Your file Number:
Contact Person:
CARRIER BILLING INFORMATION
Carrier: Bill to Customer:
Adjuster Name:
Address:
City: State: Zip:
Phone: Fax:
Claim/File Number:
Name of Insured:
Date of Loss:
NOTICE TO OPPOSING COUNSEL
INFORMATION
Opposing Counsel’s Name:
Firm:
Address:
City: State: Zip:
Phone: Fax:
List of Opposing Counsel Attached:
RECORDS PERTAINING TO
Subject’s Name:
A.K.A.:
S.S.#: DOB:
SUBPOENA INFORMATION
AUTHORIZA
TION SUBPOENA ENCL ARRANGED
PREPARE SUBPOENA Depo WCAB Trial
SUBPOENA FOR Records Only Personal Appearance Only
Appearance With Records APPEARANCE ADDRESS
(Below)
WCAB JUDGE NAME:
DATE: Time: DEPT-DIV.:
COURT Superior WCAB Federal
ARBITRATION American Uninsured Motorist
CASE NO:
COURT NAME:
CASE NAME:
VS:
YOUR FIRM REPRESENTS:
P. 877.591.9979
F. 213.802.0810
Addr:
Plaintiff:
Def:
Other:
1511 West Beverly Blvd
Los Angeles, CA 90026
www.firstlegal.com
FRRorders@firstlegal.com
Copy Specific Date’s Only / Dates:
Phone:
(MARK BOX FOR RECORDS NEEDED BELOW)
MED BILLS X-RAYS SIGN-IN PSYCH EMPLY INSUR ACDEMC
PATH MTRLS OTHER
Copy Specific Date’s Only / Dates:
Phone:
(MARK BOX FOR RECORDS NEEDED BELOW)
MED BILLS X-RAYS SIGN-IN PSYCH EMPLY INSUR ACDEMC
PATH MTRLS OTHER
Copy Specific Date’s Only / Dates:
Phone:
(MARK BOX FOR RECORDS NEEDED BELOW)
MED BILLS X-RAYS SIGN-IN PSYCH EMPLY INSUR ACDEMC
PATH MTRLS OTHER
Copy Specific Date’s Only / Dates:
Phone:
(MARK BOX FOR RECORDS NEEDED BELOW)
MED BILLS X-RAYS SIGN-IN PSYCH EMPLY INSUR ACDEMC
PATH MTRLS OTHER
Copy Specific Date’s Only / Dates:
Phone:
(MARK BOX FOR RECORDS NEEDED BELOW)
MED BILLS X-RAYS SIGN-IN PSYCH EMPLY INSUR ACDEMC
PATH MTRLS OTHER
Copy Specific Date’s Only / Dates:
Phone:
(MARK BOX FOR RECORDS NEEDED BELOW)
MED BILLS X-RAYS SIGN-IN PSYCH EMPLY INSUR ACDEMC
PATH MTRLS OTHER
Copy Specific Date’s Only / Dates:
Phone:
(MARK BOX FOR RECORDS NEEDED BELOW)
MED BILLS X-RAYS SIGN-IN PSYCH EMPLY INSUR ACDEMC
PATH MTRLS OTHER
Copy Specific Date’s Only / Dates:
Phone:
(MARK BOX FOR RECORDS NEEDED BELOW)
MED BILLS X-RAYS SIGN-IN PSYCH EMPLY INSUR ACDEMC
PATH MTRLS OTHER
RECORDS LOCATIONS
1. Location:
Address:
Additional Info:
2. Location:
Address:
Additional Info:
3. Location:
Address:
Additional Info:
4. Location:
Address:
Additional Info:
5. Location:
Address:
Additional Info:
6. Location:
Address:
Additional Info:
7. Location:
Address:
Additional Info:
8. Location:
Address:
Additional Info:
Send Additional Sets to:
P. 877.591.9979
F. 213.802.0810
1511 West Beverly Blvd
Los Angeles, CA 90026
www.firstlegal.com
FRRorders@firstlegal.com
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CARRIER BILLING INFORMATION CUSTOMER INFORMATION

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Completed 16 January 2021

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