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Workers' Compensation File Transmittal
Wai & Connor, LLP
2566 Overland Avenue, Suite 570
Los Angeles, CA 90064
Tel (310) 838-6800 Fax (310) 838-7700
Claimant _________________ Employer _________________
Date of Injury _________________ Date of Birth _________________
Claim No. _________________ WCAB No. _________________
Date Claim Form received by Employer ______________________________
Date Claim Form has been / should be denied ______________________________
Weekly earnings _________________ TD Rate _________________
Total TD Paid _________________ Period Covered _________________
Total PD Paid _________________ Period Covered _________________
Total VRMA Paid _________________ Period Covered _________________
Suggested Issues:
AOE / COE Need for further medical
Coverage date Self-procured medical
Date of injury Medical legal costs
TD Statute of Limitations
PD Rehabilitation
Apportionment Subrogation
Other __________________________________________________________
Date and Time Hearing Set Yes No
Investigation Assigned Yes No
Do we have authority to    
   set deposition Yes No
   set defense examinations Yes No
   subpoena records Yes No
   tender lien objections Yes No
Remarks    
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