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 Workers' CompensationL&H132aS&WIDR for Safety OfficersCal/OSHA
hearing Information YesNo
Type of Hearing
hearing Type
Place
hearing Place
Date & Time
hearing date
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
Your Name
contactEmail
contactPhone
contactFax
contactCompany
contactInsurersName
contactAddress
contactCity
Filter State*AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY
contactPolicyNumber
Hanna Brophy Office
toOffice Select OneBakersfieldFresnoLodiLos AngelesOaklandOrangeReddingRiversideSacramentoSALINASSan DiegoSan FranciscoSan JoseSanta RosaVan Nuys
Hanna Brophy Attorney
toAttorney Select One
benefitsTD
benefitsVR
benefitsPD
benefitsTDperiod
benefitsVRperiod
benefitsPDperiod
paidMedicalExpenses
paidVrExpenses
issue checkbox ApportionmentCoverageDependencyEarningsEmploymentFuture MedicalInjury AOE/COEJurisdictionOccupationOtherPast MedicalPermanent DisabilityS&WStatute of LimitationsTemporary Disability132a
Depose Applicant*
deposeApplicant YesNo
Schedule Medical Exam*
medicalExamScheduled YesNo
Physician
physicianName
comments
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