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Ordering Firm Billing Firm
Firm Name 
Attorney 
Address 
City, State, Zip 
Phone 
File number 
Representing Plaintiff/Claimant
Defendant
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Attention 
Address 
City,State,Zip 
Phone 
Claim number 
Ship To
Firm Name 
Attention 
Address 
City, State, Zip 
Phone 
Firm Name 
Attention 
Address 
City,State,Zip 
Phone 
Send Notices To (Consumer's notice- CCP1985.3 & 1985.6)
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Attention 
Address 
City, State, Zip 
Phone 
Firm Name 
Attention 
Address 
City,State,Zip 
Phone 
Case Information
Plaintiff 
vs. Defendant 
Case Number 
Country/District 
 Superior
 Mini
 W.C.A.B.
 U.S.D.C.
 U.M. Arbitration
 Other
Records Pertaining To
Name 
AKA 
Date of Birth 
Medical Records # 
DOI 
SSN 
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E = Employment      A = Academic      P = Payroll      I = Insurance
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