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.

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

Your Name*

Email

Phone*

Fax*

Company Name

Insurer's Name*

Address*

City*

State

Policy #*

To

Hanna Brophy Office

Hanna Brophy Attorney

Benefits paid

TD

Rate

Period

PD*

Rate*

Period*

Medical Expenses

VR Expenses

Defense Discovery Requested

Physician

Comments

Upload Your Case:

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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.

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Referrals

Event title

Case Information

From

To

Benefits paid

Defense Discovery Requested