31316 Via Colinas, Suite 108, Westlake Village, CA 91362
Tel: (818) 991-9120 Fax: (818) 991-9125
www.esquirecopy.com
Instructions:
1. Fill out the form and click "Preview"
2. Click submit on preview page to complete order
ORDER DATE:
07/30/2010
DATE NEEDED:
mm/dd/yyyy
Special Handling:
Rush
Reason: AME, Trial, MSC etc.
Send Invoice to:
Requestor
Carrier
1. COPY RECORDS PERTAINING TO
First Name:
Middle Name:
Last Name:
SSN:
No SSN available
AKA:
AKA SSN:
Date of Birth:
mm/dd/yyyy
Date of Injury:
3. CARRIER - INSURANCE COMPANY
Carrier:
Address:
City:
State:
Zip:
-
Adjuster:
Phone:
Ext:
Fax:
Insured
Claim No:
5. OPPOSING COUNSEL #1
Firm:
Address:
City:
State:
Zip:
-
Attorney:
Phone:
Ext:
Fax:
Representing:
Plaintiff/Applicant
Defendant
Other
2. REQUESTED BY
Firm:
Address:
City:
State:
Zip:
-
Representing:
Plaintiff/Applicant
Defendant
Other
Attorney/Other:
Our File No:
Contact:
To obtain a copy of this request, please be sure to enter your email address below.
Email:
Phone:
Ext:
Fax:
4. SUBPOENA INFORMATION
Case No:
Case Caption:
VS:
County:
Judicial District:
Department/Division:
Appearance Address:
City:
State:
Zip:
-
Appear On Date:
mm/dd/yyyy
Request Type:
SUPERIOR
FED
ARB
Client Subpoena
WCAB
Authorization Attached
Personal Injury Case
Prepare:
Deposition Subpoena
Trial Subpoena
Worker's Comp Subpoena
Trial Date:
mm/dd/yyyy
Delivery Cutoff Date:
mm/dd/yyyy
For:
Records Only
Seal Records To Trial
Personal Appearance W/ Records
Personal Appearance W/O Records
6. RECORDS AND DELIVERY #1
Record Type:
Medical
Billing
Original Films
Duplicate Films
Employment
Wage
Claim File
Edex Report
Psychiatric
Other
Location Name:
Address:
City:
State:
Zip:
-
Phone:
Ext:
Copy:
Any and All
OR
These Dates Only:
Begin:
mm/dd/yyyy
End:
mm/dd/yyyy
Addendum - Will be printed on pleading paper
Special Instructions
Deliver Above Record To
Name:
Address:
City:
State:
Zip:
-
Copies Required:
Paper:
CD: