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.

Case type

Hearing information

hearing Information
YesNo

Type of Hearing

hearing Type

Place

hearing Place

Date & Time

hearing date

Case Information

Claim #*

contactClaimNumber

Employee Name*

employeeName

Date of Birth*

employee Birthday Date

Occupation*

employee Occupation

Policy Period*

employee policy period

Date of Injury*

employeeinjurydate

Body Parts

employeeBodyParts

Employee's Attorney

employeeAttorney

Application Filed On

applicationFileDate

Is the case admitted, denied, or on delay?

admittedDeniedDelay

If denied, what was the denial date?

danialLetterDate

File Answer*

fileAnswer
YesNo

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

decisionDate

From

Your Name

contactEmail

contactPhone

contactFax

contactCompany

contactInsurersName

contactAddress

contactCity

Filter

contactPolicyNumber

To

Hanna Brophy Office

toOffice

Hanna Brophy Attorney

toAttorney

Benefits paid

benefitsTD

benefitsVR

benefitsPD

benefitsTDperiod

benefitsVRperiod

benefitsPDperiod

paidMedicalExpenses

paidVrExpenses

defense discovery requested

Depose Applicant*

deposeApplicant
YesNo

Schedule Medical Exam*

medicalExamScheduled
YesNo

Physician

physicianName

Comments

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.

Upload Your Case:
uploadedfile

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Referrals

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