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LWD Home > Temporary Disability > Employer/Insurer > State Disability Benefits > Request an Independent Medical Examination

Request an Independent Medical Examination

    

Please complete the information below, if you wish to request that an employee be evaluated by a physician selected by this agency. Be sure to complete all the information, including the reason why you feel this examination is necessary. 

Claimant's Name:  
 
Date Disability Began:  
 
Reason for Request:    
 
Company's Name  
 
Your Name:  
 
Your Telephone No:  
 
Your E-Mail Address:  
 


  

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