Varon, St.Clair & Jelensky, APC

Varon, St.Clair and Jelensky specializes in representing employers, third party administrators and insurance carriers in the defense of workers’ compensation claims throughout Southern California. Our attorneys have over 60 years of combined legal experience. The Firm utilizes a proactive, collaborative approach to achieve quick, cost-efficient and superior results.

Attorneys

Michael V. Varon | David A. St.Clair | Scott T. Jelensky

Venues

Our attorneys handle matters before the following Workers’ Compensation Appeals Boards in Southern California:

Contact

Michael V. Varon: mvaron@vsjlaw.com
David A. St. Clair: dst.clair@vsjlaw.com
Scott Jelensky: sjelensky@vsjlaw.com

Phone: (714) 804-5464
Fax: (714) 804-5474

Varon, St.Clair & Jelensky, APC
515 Cabrillo Park Drive, Suite 311
Santa Ana, California 92701

Litigation Referral

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LITIGATION REFERRAL FORM

Name:

Phone Number:

Fax Number:

Company Name:

TPA/Insurer Name:

Employer:

Claim #:

CASE INFORMATION
Select all that apply:

CA Work Comp

Subrogation

132a

S&W

Other

Applicant:

DOB:

Occupation:

Policy Period

Date of Injury:

Body Part(s):

Applicant Attorney:

Address:

Telephone:

BENEFITS PAID

AWW ($):

TD ($):

Rate ($):

Periods:

PD ($):

Rate ($):

Periods:

Medical Expenses ($):

SUGGESTED ISSUES

Injury AOE/COE

Employment

Occupation

Coverage

Earnings/AWW

Temp Disability

Perm Disability

Apportionment

MPN/UR/IMR

Future Medical

Statute of Limitations

Jurisdiction

Dependency/Death Benefits

Subrogation

132a

S&W

Contribution/Reimbursement

Employment Defense

ADR

Other

Special Handling Instructions:

SIGNATURE OF ADJUSTER

Adjuster Name

Date:

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