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A California Workers' Compensation Law Firm
Referrals
Refer a Case
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Applicant Name
Referrer Company Name
Email
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Phone
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Claim Number
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Comments/Details of Case
Issues for Litigation Assignment
*
Please check all that apply.
Employment
Coverage
Injury AOE/COE
Statue of Limitations
Occupation
Average Earnings
Entitlement to Temporary Disability
Entitlement to Permanent Disability
Medical Treatment
Panel QME Needed
132a Defense
Serious and Willful Misconduct Defense
Dependency
Subrogation
Other
Has a wage statement been requested?
Yes
No
Has the personnel file been requested?
Yes
No
Do we have authority to do the following?
Please select all that apply.
Schedule deposition
Subpoena records
Request Panel QME
Arrange employer level investigation
Arrange surveillance investigation
Other
Thank you!