Gray and Prouty - A Professional Law Organization

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law offices of

Gray & Prouty

a professional corporation

CRESCENT CITY OFFICE

1585 SOUTH RAILROAD AVE.

CRESCENT CITY, CA 95531

PHONE (707) 464-6730

FAX (707) 464-6740

EMAIL: crescentcity@grayandprouty.com

www.grayandprouty.com

REFERRAL FORM

FULL REFERRAL

LEGAL ANALYSIS ONLY

RATING REQUEST

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DOB:

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MEDICAL PAID:

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DWC-1

L.C. 5402

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COVERAGE

INJURY AOE-COE

EMPLOYMENT

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L.C. 4650(D)

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SELF PROCURED MEDICAL

JURISDICTION

OTHER

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	Rating Referral Form - PDF Format
	RIVERSIDE (951) 353-8750 FAX (951) 353-1074		OAKLAND (510) 893-6000 FAX (916) 419-6663
REDDING (530) 246-9061 FAX (530) 246-0781	SACRAMENTO (916) 419-6662 FAX (916) 419-6663	SANTA ANA-ORANGE (714) 558-3751 FAX (714) 973-4736	SALINAS (831) 444-7736 FAX (916) 419-6663	CRESCENT CITY (707) 464-6730 FAX (707) 464-6740

BILL K. GRAY CHRISTOPHER COOLEY PETER E. CUMMINGS	JOHN P. WELCH, INC. TRACY STURTEVANT THOMAS E. YOUNGDALE	MARILEE B. HAZEN GEHRING C. PROUTY 1947-1998	STEPHEN M. BERGER JOSEPH A. HERNANDEZ JAMES C. HAZEN	JOANNE MARECEK JOHN R. BANKS

		OF COUNSEL
JAMES B. JAMES ANDREW J. BLACKBURN	MALCOLM D. SCHNICK JOHN G. MCKAVENEY	HELEN M. BATHER JASON P. WILLIAMS	DAWN C. NELMS THOMAS W. PALECEK	T.KELLY COX MEGAN L. MCKENZIE

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