LEGAL E-REFERRAL FORM Direct referral to attorney:CASE INFORMATIONApplicant name:Applicant DOB:Employer name:ADJUSTER INFORMATIONAdjuster Name:Adjuster Email Address:Adjuster Phone:EMPLOYER INFORMATIONEmployer Contact Name:Employer Email Address:Employer Phone:APPLICANT ATTORNEY INFORMATIONAttorney Name:Attorney Phone: CLAIM DATAClaim Number:WCAB Number:Date of Injury:Admitted:YesNoDelayed:YesNoDenial DateParts of Body Denied/Disputed:Hearing Scheduled:YesNoHearing Date:Hearing Time:Board:Continuous Handling:YesWalk Through Settlement Only:YesDeposition Authorized:YesNo Submit ReferralThis field should be left blank
