Rating Requestluis@pdratings.comcraig@pdratings.com(415) 861-4040 Name * First Name Last Name Email Address * Carrier/Adjust. Agency Direct Number (###) ### #### Billing Email Address Billing Address Address 1 Address 2 City State/Province Zip/Postal Code Country Service Requested Service Level * Basic Consultative Rating PD Rating Analysis Optional Rush Services Rush Services are intended for Basic Rating Requests ONLY 1 Business Day ($85) 2 Business Days ($60) Schedule 13 PDRS (Adjustments) 05 PDRS 97 PDRS 88 PDRS 97 & 05 PDRS Employee / Claim Information Employee Name First Name Last Name Claim Number Employer Occupation or Occ. Group # Date of Injury (Specific or CT) MM DD YYYY Date of Birth MM DD YYYY Age of Employee on Injury Date Injuries to Joint / Organ / Body Segment or Systems Medical Report PTP PTP Consult PQME APQME AME Other Medical File / Multiple Reports Remarks / Special Instructions Please email medical report as an attachment to luis@pdratings.com Thank you!Please email PDF medical reports to luis@pdratings.com or craig@pdratings.com.