California > Workers Comp > General
Audit Referral Form DWC-AU-906 - California
| Audit Referral Form Form. This is a California form and can be used in General Workers Comp . |
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AUDIT REFERRAL FORM __________________________________ Claims administrator / Company name __________________________________ Injured worker name __________________________________ Address __________________________________ Claim number __________________________________ City, state, ZIP __________________________________ Date of injury __________________________________ Date or period of violations __________________________________ Employer SPECIFIC DETAILS OF COMPLAINT List the nature of the complaint, being as specific as possible. For example, late payments of temporary or permanent disability (the number of late payments, if known), failure to pay temporary or permanent disability, vocational rehabilitation maintenance allowance, or 10% selfimposed penalties for late payments (indicate the periods not paid, if known), failure to provide vocational rehabilitation services when indicated, failure to pay or object to medical treatment or medical-legal bills, failure to investigate a claim, unsupported denial of liability for a claim, et al. Please attach copies of supporting documentation, if available. _____________________________________ Complainant (name & title) _____________________________________ Address, city, state, ZIP ________________________ Date Form DWC-AU-906 (Rev 06/06) American LegalNet, Inc. www.USCourtForms.com
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