Refer a Case - Workers Comp Litigation Support - Hanna Brophy

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:

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

Case Information

From

To

Benefits paid

Defense Discovery Requested