Demand Letters

Demand treatment, employment records, reimbursement, and much more for your worker's compensation claim. DIY Work Comp will write and send the demand letters to your employer on your behalf.

Legal First Name

Legal Last Name

Address

Which Demand Letters do you need? (select all that apply) *

Employment Records

More Treatment

Qualified Medical Evaluator (QME)

Temporary Total Disability (TTD)

Work Accommodation/Interactive Process

Medical Cost Reimbursement/Mileage

Resolution of Claim/Settlement

Employer Company Name

Employer Address

Date of Injury

ADJ/Claim Number

Body Parts Injured (select all that apply): *

AbdomenAnkleArmBackBrainChestCirculatory SystemCOVID-19Digestive SystemEar(s)Excretory SystemEye(s)FaceFinger(s)Foot/FeetHand(s)HerniaHip(s)JawKnee(s)Leg(s)Lower ExtremitiesLower LegMouthMusculoskeletal SystemNeckNervous SystemNoseReproductive SystemRespiratory SystemScalpShoulder(s)SkinSkullTeethThigh(s)Toe(s)TrunkUpper ExtremitiesWrist(s)Other/Unclassified

What specific medical treatment do you need?

Date Last Paid

Were you treated by a doctor for your injury?

Yes

No

Doctor Name

Treatment Location

Were you given any work restrictions?

Yes

No

Describe Work Restrictions

Describe Treatment Received

Amount Paid or Are Responsible For

Amount You Are Demanding

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DIY Work Comp

Simplifying the California Worker's Compensation System

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