Workers Compensation Insurance

Patient Name:		Date of Injury:
Employer:		Phone:
Contact Person:
Have you notified your employer of this injury? yes  no
WComp Insurance Company
Name:
Address:
Phone:
Adjuster/Contact Name:
Telephone Extension:
Claim #:
Fax #:
Utilization Review Company
Name:
Address:
Phone:
UR/Contact Name:
Telephone Extension:
Fax #: