Litigation Referral ← BackThank you for your response. ✨ LITIGATION REFERRAL FORM Name:(required) Phone Number:(required) Fax Number: Company Name:(required) TPA/Insurer Name:(required) Employer:(required) Claim #:(required) CASE INFORMATION Select all that apply: CA Work Comp Subrogation 132a S&W Other Applicant:(required) DOB:(required) Occupation:(required) Policy Period(required) Date of Injury: (required) Body Part(s):(required) Applicant Attorney:(required) Address:(required) Telephone:(required) 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(required) Date:(required) By clicking this checkbox, you are electronically signing this form.(required) Submit Δ
Varon, St.Clair & Jelensky, APC 