Jeff Malmuth & Co.

Diminished Future Earning Capacity (DFEC) Report

Thank you for considering a low-cost ($125.95) Estimated Diminished Future Earning Capacity report. With the information you provide I will furnish you with the results of our preliminary evaluation in the form of a report. You can use this report to document your file that you considered utilizing a DFEC report in your case. Some attorneys are using our reports during negotiations at MSC's.
Phone: (415) 362-7005
Fax: (415) 362-7040

If you have voucher eligible clients, please consider referring them for Voucher-Training.

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Referring Attorney

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Client Information: WCAB No: Claim No:

Last Name: First Name:

Phone: Cell Phone:

Street Address: City: Zip Code:

DOI: P&S Date:

Date of Birth: Wages at DOI:

Occupational Group #: Job Title at DOI:

Wages post-DOI: Employer/City of Employer at DOI(for EDD):

Work Restrictions/Functional Limitations(Please send/fax relevant medical reports):

Impairment Number / Impairment: Corresponding WPIs: % Apportionment to Non-Industrial (if applicable):
(Attach additional impairments if needed) (Unadjusted for age and occupation)
Example: 15.01.01.00/Cervical Spine DRE 8%WPI 10%

Rating Strings for Each Body Part (Attach DEU Ratings, If available):

Please submit and pay electronically or send a check in the amount of $125.95 for each referral. We anticipate a one week turnaround. For RUSH orders please call us at (415) 362-7005.

If you have any questions, do not hestitate to contact me or my staff.
Thank You, Jeff Malmuth

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We reserve the right, at any time after receipt of your order, to accept or decline your order for any reason.

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