Worker's Compensation Verification Form Email Worker's Compensation Verification Form First Name: * Last Name: * Email Address: * DOB: * Body Parts included in Case: * Date of Injury: * Carrier Case #: * WCB #: * WC Carrier Name: * WC Carrier Address: * Phone Number: * Fax Number: Adjuster Name: * Adjuster Phone Number: * Variance Fax Number: Employer Name: * Employer Phone Number: * Employer Address: * Have you been scheduled for an Independent Medical Exam? * Yes No
