Services Requested:
SJDB - Temporary modified/alternate offer
SJDB - Permanent modified/alternative offer
RU94 - Permanent modified/alternative offer
Other:

Fax or E-mail over job description of the usual and customary occupation if available
Fax or E-mail over report confirming permanent or temporary work restrictions if available

Injured Worker Claim Number: Social Security Number: Injured Worker: Telephone: Street Address: City: State: Zip: Date of Birth: Occupation at Date of Injury: Date of Injury: Specific       CT AWE/Wages: Injury/body part: Date of Hire:

Employer Employer: Telephone: Contact person: Fax: Street Address: City: State: Zip: E-mail:

Claims Professional Claims Professional: Telephone: Street Address: City: State: Zip: E-mail: Fax: Firm: Date of Referral:

Applicant Attorney Applicant Attorney: Telephone: Address: City: State: Zip:

Physician Treating MD: Telephone: Street Address: City: State: Zip: P & S?    Yes - Date:     No Last Appt. Date: Next Appt. Date:

Other Provider Other Provider: Telephone: Street Address: City: State: Zip: P & S?    Yes - Date:     No

Work Restrictions

Misc. Comments

Please Enter Dates: Date RTW temporary mod/alt duties: Date RTW permanent mod/alt duties: Date last TD payment was mailed: Date ending TD notice was mailed: Date SJDB advise letter was mailed: