HomeAttorneysServicesLitigation ReferralJake's eBlastPDRaterThe Comp Guys

SAN FRANCISCO

One Embarcadero Ctr.

Suite 1520

San Francisco, CA 94111

Phone: (415) 398-3198

Fax: (866) 563-0092

 

OAKLAND

475-14th Street

Suite 500

Oakland, CA 94612

Phone: (510) 645-7172

Fax: (866) 563-0092

 

ENCINO

16030 Ventura Boulevard

Suite 450

Encino, CA 91436

Phone:  (818)205-1215

Fax: (866)563-0092

 

                                    

 

 

Litigation Referral 
Please fill out the following online referral form. To download and save an editable copy of this referral form please select the PDF Referral Form link at the top right hand side of your screen:

Client Information
Adjuster:
Carrier/TPA/Self-Adm Employer:
Address:
City:
State:
Zip Code:
Phone:
Fax:
Email Address:
Employer Information
Employer:
Address:
City:
State:
Zip Code:
Phone:
Fax:
Title:
Employee Information
Employment
Insurance
Injury - AOE-COE
Injury - Nature/Extent
Earinigs
Occupation
Medical Tx
Temp Disibility
Perm Disibility
Appointment
15% Plus or Minus
Dependency
Statute of Limitations
VR/SJDB
Liens
Contribution/Other
Comment::
Critical Issues:
90 Day Decision Due:
Temporary Disability First Paid:
Temporary Disability Rate:
From:
To:
From:
To:
Permanent Advances $:
Input field
Benefit Printout provided
Total Medical Paid $:
Offer Alt/Mod/Reg Work:
Date:
From:
Hearing Scheduled for:
Comment
Scheduled Medical Exam
Depo of
File DOR
Prepare Appeal Due
Requested Attorney
Office Location
Security code:
 *
Do not enter anything in this field:

* indicates a required field
 
 

 

Certified Specialist, Workers' Compensation Law The State Bar of California Board of Legal Specialization

Shaw, Jacobsmeyer, Crain & Claffey, LLP
475 14th Street Suite 500, Oakland, CA 94612 Phone:(510) 645-7172 Fax (866) 563-0092

This Website Designed using the
iBuilt Website Builder