Worker Compensation Law Firm Defense for Los Angeles, San Diego, CA and Nevada

ONLINE LITIGATION REFERRAL FORM

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Office:			Office

Current Date:			01/05/2009	From:
Phone:				Email:

Depo Authorized:			Yes No	Applicant:
Date of Injury:				Age:
Occupation:				Earnings:	$
Date of Hearing:

Insured:				Self Insured:
Insurance Carrier:				Liquidated Carrier:

Applicant SSN:

TPA:
Type of Injury/Parts of Body:
Admitted Injury:				If not what Date Denied:
Date Delayed:				Dates of Coverage:
Total Medical Paid		$		WCAB #:
Claim #:

TD	Paid	$
	From			To
	Weekly Rate	$		Liens	$

PD	Paid	$
	From			To
	Weekly Rate	$		Liens	$

Suggested Issues:			Check all that apply
			Employment	Temporary Disability
			Occupation	Further Medical Care
			Injury	Self-Procured Medical Care
			Insurance Coverage	Vocational Rehabilitation
			Permanent Disability	Earnings
			Dependency	Statute of Limitations
			Apportionment	Jurisdiction
			Subrogation

Investigation in Progress:			Check all that apply
			Medical Records Being Obtained	Employment Records Being Obtained
			Job Description Solicited	Sub Rosa Investigation Ordered
			Records Subpoenaed	Records Subpoenaed Pending Receipt

			Medical Examination:	Set for date: With Dr.:


Other:

Remarks: