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

Insurance / Legal

Delivered by courier

<

<

<<CITY/PROV>>

< >

Dear <

RE: < > < >

DOB:< >

DOL:< >

Date/Time: < > @<< TIME>>

Report Due: <<report due date>>

Thank you for agreeing to perform a <<Functional Capacity Evaluation>> on this person.

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

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

Our client wishes to determine the level of disability for a return to either the pre-accident of some other type of employment.

The adjuster states that:

INSERT TAST

We enclose all documentation that has been made available to us. Please see the attached letter from our client, < > of < >, dated <<LOI DATE>> with background issues and questions to be addressed in your report. Please respond in a question and answer format.

Please obtain a detailed history, review the enclosed documentation, perform an appropriate examination, and provide your opinion on the following points:

-

-

-

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

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

Thank you for providing your services in this matter.

Yours sincerely,

Western Medical Assessments Corporation

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

Medical Director

RGH/sz

Encls.