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Check Request


   Adjuster Information
Request To:
Fax #:
Date Needed:
Request From:
Injured Worker:
Claim #:
Amount of Check:
For:
(Records,
Rehab Conference, Medical Records, Etc.)
Conference Date:
Check written to:
Tax ID:

Please write check to the person in the Check written to area. 
Mail check to : Younger and Associates, PO Box 1181, Mandeville, La. 70470.