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EXPEDITED SERVICE REQUESTED No Yes

SEE COMMENTS/INSTRUCTIONS No Yes

GENERAL INFORMATION
Name:
Address:
Birth Date (MM/DD/YEAR):
Accident Date (MM/DD/YEAR):
SSN:
DOCUMENT LOCATIONS #1
Location:
Type of Records:
Address:
Phone Number:
Copy Records:
Other Documents:	Copy X-Ray Films Medical Bills Inpatient Outpatient Emergency Room
Copy Specific Date:	From To ONLY
Specific Instructions:

DOCUMENT LOCATIONS #2
Location:
Type of Records:
Address:
Phone Number:
Copy Records:
Other Documents:	Copy X-Ray Films Medical Bills Inpatient Outpatient Emergency Room
Copy Specific Date:	From To ONLY
Specific Instructions:
Go to Additional Locations
CASE INFORMATION
Case Caption:
Court/Term/Number:
WC Judge:
Bureau Number:
Party You Represent:	Defendant Plaintiff
AUTHORIZATION(s):	Attached Obtain from Plaintiff Co
Go to Requesting Counsel
Top of Page
OPPOSING COUNSEL
Opposing Counsel:
Firm:
Phone:
Address:

Other Counsel:
Phone:
Address:

Other Counsel:
Phone:
Address:
Top of Page
REQUESTING COUNSEL
*Requested by: (attorney name)
Date (MM/DD/YEAR):
Authorization to Sign Documents and Serve Subpoena: Yes No
Firm Name:
Your ID Number:
Your File Number:
Address:
Phone:	Fax:
Paralegal/Secty:
*Email:

Bill to:
Address:
City, State Zip:
Attention:
Claim Number:
Copy Format:	Paper CD

Comments/Instructions:
Go to Submit / Print Form / Clear Form
ADDITIONAL LOCATIONS
DOCUMENT LOCATIONS #3
Location:
Type of Records:
Address:
Phone Number:
Copy Records:
Other Documents:	Copy X-Ray Films Medical Bills Inpatient Outpatient Emergency Room
Copy Specific Date:	From To ONLY
Specific Instructions:
Top of Page Go to Requesting Counsel Go to Case Information
DOCUMENT LOCATIONS #4
Location:
Type of Records:
Address:
Phone Number:
Copy Records:
Other Documents:	Copy X-Ray Films Medical Bills Inpatient Outpatient Emergency Room
Copy Specific Date:	From To ONLY
Specific Instructions:

DOCUMENT LOCATIONS #5
Location:
Type of Records:
Address:
Phone Number:
Copy Records:
Other Documents:	Copy X-Ray Films Medical Bills Inpatient Outpatient Emergency Room
Copy Specific Date:	From To ONLY
Specific Instructions:
Top of Page Go to Requesting Counsel Go to Case Information
DOCUMENT LOCATIONS #6
Location:
Type of Records:
Address:
Phone Number:
Copy Records:
Other Documents:	Copy X-Ray Films Medical Bills Inpatient Outpatient Emergency Room
Copy Specific Date:	From To ONLY
Specific Instructions:

DOCUMENT LOCATIONS #7
Location:
Type of Records:
Address:
Phone Number:
Copy Records:
Other Documents:	Copy X-Ray Films Medical Bills Inpatient Outpatient Emergency Room
Copy Specific Date:	From To ONLY
Specific Instructions:

DOCUMENT LOCATIONS #8
Location:
Type of Records:
Address:
Phone Number:
Copy Records:
Other Documents:	Copy X-Ray Films Medical Bills Inpatient Outpatient Emergency Room
Copy Specific Date:	From To ONLY
Specific Instructions:
Top of Page Go to Requesting Counsel Go to Case Information
DOCUMENT LOCATIONS #9
Location:
Type of Records:
Address:
Phone Number:
Copy Records:
Other Documents:	Copy X-Ray Films Medical Bills Inpatient Outpatient Emergency Room
Copy Specific Date:	From To ONLY
Specific Instructions:

DOCUMENT LOCATIONS #10
Location:
Type of Records:
Address:
Phone Number:
Copy Records:
Other Documents:	Copy X-Ray Films Medical Bills Inpatient Outpatient Emergency Room
Copy Specific Date:	From To ONLY
Specific Instructions:

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Main Office: 4940 Disston Street Philadelphia, PA 19135-2089
Phone: 800.436.1479
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