Fill and Sign the Requests Production Form

BEFORE THE ___________ WORKERS’ COMPENSATION COMMISSION CLAIMANT )       ) V. ) EMPLOYER ) WCC NO.       ) ) AND ) ) CARRIER )       )             REQUEST FOR PRODUCTION OF DOCUMENTS TO CARRIER TO THE DEFENDANT, ______________________________________________ TO ITS ATTORNEY OF RECORD: Pursuant to the rules of the __________ Workers' Compensation Commission, Claimant hereby requests you to produce and permit the inspection and copying of the following documents within thirty (30) days after receipt thereof by your attorneys at the office of counsel for ________ located __________________________________ The term "documents" includes, but is not limited to, all handwritten, typed, printed and Photostatted matter, and drafts, duplicates, carbon copies or any other copy thereof, in the possession, custody or control of the Carrier or the counsel for the Employer and Carrier including without limiting the generality of the definition all letters, correspondence, memoranda, notes, reports, statements, paraphrases of statements, drawings, tape recordings, graphs and harts, printouts and computations, work papers, studies, agreements, contracts, and records of telephone calls in the possession, control or custody of the Carrier or its attorney. The manner of inspection shall be personal inspection including the copying and photographing by or on behalf of the Claimant the following mentioned documents, and other tangible things, not privileged. 1. The entire claim file of __________________ concerning ________________. 2. Please produce a copy of each and every medical, hospital, drug or doctor's bill in your possession not previously provided to the Claimant incurred by Claimant in connection with the injuries and/or medical condition for which claim is made herein. 3. Please produce a copy of each and every medical report in your possession concerning Claimant, ______________________. 4. Please produce a copy of each and every document filed by ____________________ with the __________ Workers' Compensation Commission in connection with the injuries sustained by _____________________ while an employee at ____________________. Respectfully submitted on this the _______ day of _________, A. D., 20___. __________ ATTORNEYS FOR THE CLAIMANT BY: CERTIFICATE OF SERVICE This is to certify that I, _________________ have this day furnished a true and correct copy of the above and foregoing Request For Production of Documents To Carrier to Hon. ________________ Attorney at Law, by placing same in the United States Mail, postage prepaid, and mailing to him at his usual office address. This the _______ day of __________ A. D., 20____. __________ ATTORNEYS FOR THE CLAIMANT BY: