Rating Request Form

raul@ratingenterprises.com
(559) 862-8480

Name:

First Name

Last Name

Email:

Firm/Company:

Date:

YYYY

Applicant/Injured Worker:

Employer:

ADJ #

Claim #

DOI:

Date of Birth:

Occupation (If occupation in dispute, please send job analysis/job description):

Name of Medical Evaluator:

Date of Report:

YYYY

DEU rating issued? If so, please attach send

Yes

PD Rate:

Comments/Important Issues:

Optional Rush Service

*Please email all medical reports and documents