Common Contracts
1 similar Rating Agreement contracts
RateFast Express Impairment Rating AgreementRating Agreement • October 6th, 2021
Employee Information Name (Last, First, Middle): Date of Injury (MM/DD/YYYY): Date of Birth (MM/DD/YYYY): Claim Number: Employer: Claims Administrator Information Company Name: Contact Name: Address: City: State: Zip Code: Phone: Fax: E-mail Address: Vendor Service Information Vendor Name: RateFast Contact Name: Chris Hall Address: 125 S. Main Street, Ste. 409 City: Sebastopol State: CA Zip Code: 95472 Phone: (707) 304-5949 Fax: (707) 921-7924 E-mail Address: express@rate-fast.com Tax ID Number: 46-1201548 Fee Agreement for Requested Service $975 for each body part rated, includes 50-pages chart review, includes MD Signature$150 per each additional 25-page units of chart review Authorized Agent/Claims Administrator: Date:
