subject_line
Litigation Referral
Date
*
Referral Type
*
Full file referral
Walkthrough only**
I am referring this file to
*
Darcy Luna
Taylor Shilts
Arthur Shwachman
Sandra Crawford
Charoletta Ransom
No preference
File Upload
Case Information
Applicant
*
Employer
*
Adjuster
*
Insurance Company
*
Third Party Administrator
Applicant's Attorney
Date(s) of Injury
Claim Number(s)
WCAB Case Number(s)
Venue
Body Part(s)
Applicant's Information
Date of Birth
Occupation
Average Weekly Wage
Temporary Disability Rate
Permanent Disability Rate
Issues
Employment
Occupation
Injury AOE/COE
Insurance Coverage
Permanent Disability
Temporary Disability
Future Medical Treatment
Earnings
Self-Procured Treatment
UR/IMR
Apportionment
Jurisdiction
Statute of Limitations
DFEC/Dahl
Dependency
Liens
S&W Misconduct
132a
Fraud
Other
Other
Pertinent Information
Is there a decision date?
Yes
No
If yes, please list the decision date(s) and date(s) of injury
Is there an AME/QME?
Yes
No
If yes, please list the name(s) of doctor(s)
If yes, please list the evaluations scheduled (if applicable)
Are there any Hearings on calendar?
Yes
No
If yes, please list the Hearing information
Are there any Depositions scheduled?
Yes
No
If yes, please list the Deposition information
If no, would you like us to schedule the applicant's Deposition?
Yes
No
Additional Information
If there is any additional information you would like us to include, please provide below. Also, if there is any immediate action you would like us to take, please indicate below.
**If referral is for walkthrough purposes only, please see the walkthrough checklist for documents to incude with the referral.
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