Refer A Case workers’ compensation claim defense form

contact us

Dear Clients

Please complete this workers’ compensation claim defense form and click the “submit” button at the bottom to refer your file for defense handling to the Law Firm of Hanna & Brophy. Hanna & Brophy handles, through this referral system, only the defense of workers’ compensation claims, so do not submit this referral form if you are an injured worker looking for attorney representation.

After completing and submitting this form, please mail a copy of your file to our scanning center, P. O. Box 12488, Oakland, CA 94604-2488, and upon receipt, the new file will be set up for immediate defense handling.

* Denotes required field

Case Type
Hearing Information

Type of Hearing

Place

Date & Time




Case Information

Employee Name*

Date of Birth

Occupation*

Policy Period*

Date of Injury*

Body Parts

Employee's Attorney

Application Filed On

Denial Letter Issued On/Denial Due Date

File Answer*

 







From
To

Hanna Brophy Office*

Hanna Brophy Attorney*

Benefits Paid
Issues
Defense Discovery Requested

Depose Applicant*

Schedule Medical Exam*

Physician

Subpoena Records Source



Comments
File Upload