< ><<File No>><<Claim #>>

Insurance / Legal

Delivered by courier

<

<

<<CITY/PROV>>

< >

Dear <,Title>> < >,

RE: < > <CMFirst>>

DOB:<<CMDOB

DOL: < >

Date/Time:< >@ < >

Report Due:<<report due date>>

** This is an EVALUTION (Not an IME) **

Thank you for agreeing to evaluate this person.

Please note there will be a videographer / interpreter present for this appointment.

Please note there is a tight deadline of <<deadline DATE>>for this report.

The adjuster states that:

-

Please review the attached telephone interview and medical summary. Please respond in a question and answer format to the following questions:

Diagnosis

Treatment recommendations

Return to work recommendations

Kindly restrict your comments to your area of specialty.

When preparing your report, please address it to: < >, < >and please quote the above referenced claim number.

PLEASE ENSURE THAT YOUR REPORT AND INVOICE ARE SENT ONLY TO WESTEN MEDICAL ASSESSMENTS.

Thank you for your services in this matter.

Yours sincerely,

WESTERN MEDICAL ASSESSMENTS CORPORATION

Roger Hodkinson M.A., M.B. (Cantab), FRCPC

Medical Director

RGH/sz

Encls.