Refer a Case

Please fill out the form below to refer a case to us. Or, download our fillable form, fill it out offline, and upload it afterward.

General Information

Case type

Hearing information

Yes
No

Type of Hearing

Place

Date / Time

Date

Time

Case Information

Claim #

Employee Name

Date of Birth

Occupation

Policy Period

Date of Injury

Body Parts

Employee's Attorney

Application Filed On

Is the case admitted, denied, or on delay?

If denied, what was the denial date?

File Answer

If the case is on delay, when is the decision date?

From

Layout

Name

Email

Phone

Phone (copy)

Company Name

Insurer's Name

Address

Address Line 1

City

State

Policy #

To

Hanna Brophy Office

Hanna Brophy Attorney

Benefits paid

Layout

TD

Rate

Period

PD

Rate

Period

Medical Expenses

VR Expenses

ISSUES

Defense Discovery Requested

Depose Applicant

Yes
No

Schedule Medical Exam

Yes
No

Physician

Comments

Upload Your Case

Click or drag a file to this area to upload.

Accepted file types: pdf, doc, rtf, jpg, jpeg, gif, bmp, png, tiff, Max. file size: 300 MB.
You may attach a file of any of the following types to your request: pdf, doc, rtf, jpg, jpeg, gif, bmp, png, or tiff. File sizes are limited to 128MB. Please email the selected attorney for this file with any documents above 128 MB.

Referrals

Event title

General Information

Case Information

From

To

Benefits paid

Defense Discovery Requested