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Referrals

Event title

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.

Case type


Hearing information


Type of Hearing

Place

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











To

Hanna Brophy Office

Hanna Brophy Attorney

Benefits paid









issues


defense discovery requested

Depose Applicant*

Schedule Medical Exam*

Physician

Comments


File upload

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 10MB. Please email the selected attorney for this file with any documents above 10 MB.

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