Records Retrieval Form

Downloadable format               

Trial Date:

WCAB

CIVIL
Request Date:

RUSH:

(Reason, ie., Trial, AME, MSC, etc.)
Due Date:


  COPY RECORDS PERTAINING TO


*Name:
Injury Date:
AKA:
SSN:
or DOB:

  REQUESTOR


*Firm:
Address:
Phone:
Fax:
Attorney:
Bar No:
Contact:
Representing:
Plaintiff/Applicant
Defendant
Other


  SUBPOENA INFORMATION


*Case No:
*Case Caption:
vs:
County:
Judicial District:
Request Type:
SUP
MUN
FED
ARB
WCAB
Auth. Attached
Client Subpoena

Prepare:
Deposition Subpoena
Trial Subpoena

Discovery Cutoff Date:

For:
Records Only
Personal Appearance WITH Records
Personal Appearance WITHOUT Records

Appearance Address:
Date:
Time:
Dept/Div:

  BILLING INFORMATION



Send Invoice To:

Requestor

Carrier (provide detail below)
Carrier:
Address:
Phone:
Adjustor:
Ext:
Claim No:
Employer / Insured:
Address:
Additional Carrier List Attached


  OPPOSING COUNSEL


Carrier:
Firm:
Address:
Phone:
Representing:
Plaintiff/Applicant
Defendant
Other

Additional Counsel List Attached


  DELIVERY INSTRUCTIONS


Requestor City:
Paper
Duplex
CD

Other Qty Req'd:
Paper
Duplex
CD

Name/Address:

Additional Delivery List Attached


  OBTAIN RECORDS FROM (Use codes below to designate what records are needed from each location)


Code:
Location:
Phone:
Treat Date:
Code:
Location:
Phone:
Treat Date:
Code:
Location:
Phone:
Treat Date:
Code:
Location:
Phone:
Treat Date:

Additional Copy Locations Attached
Copy: Any and All
These Dates Only:

Special Instructions (attach claim or application form):


  COPY RECORDS PERTAINING TO:


Name:
AKA:
Code:
Location:
Phone:
Treat Date:
Code:
Location:
Phone:
Treat Date:
Code:
Location:
Phone:
Treat Date:
Code:
Location:
Phone:
Treat Date:


By Sending this order, I/we herewith authorize Kusar, Inc., and their representatives for the purpose of procuring/transferring all records in accordance with the directives contained in this order form. The party ordering the records accepts responsibility for the cost of obtaining said records. In the event a third party is billed, the ordering firm is held responsible until payment is received. The ordering party may be held liable for all costs associated with collections of this order.