Referrals LEGAL E-REFERRAL FORM Direct referral to attorney: CASE INFORMATION Applicant name: Applicant DOB: Employer name: ADJUSTER INFORMATION Adjuster Name: Adjuster Email Address: Adjuster Phone: EMPLOYER INFORMATION Employer Contact Name: Employer Email Address: Employer Phone: APPLICATION ATTORNEY INFORMATION Attorney Name: Attorney Phone: CLAIM DATA Claim Number: WCAB Number: Date of Injury: Admitted: Yes No Delayed: Yes No Denial Date Parts of Body Denied/Disputed: Hearing Scheduled: Yes No Hearing Date: Hearing Time: Board: Continuous Handling: Yes Walk through settlement only: Yes Deposition Authorized: Yes No This field should be left blank Submit Referral Please wait...
