Litigation Referral sheet for Godfrey Godfrey & Lamb, LLP

GODFREY GODFREY & LAMB, LLP
ATTORNEYS AT LAW

Litigation Referral Form

If browsing this site has led you to feel that it may be useful to add us to your panel of attorneys, please fill out and submit the litigation referral sheet form below. Or you can download, print, and fill out one of the following litigation referral sheets directly below and return to wpeterg@godfrey-law.com.

PDF format (7kB)
(requires Adobe Acrobat Reader)

Microsoft Word format (21kB)

Begin Form*:

*Submit one form per injury. (All fields are required)

Today's Date:

Date of Hearing:

Adjuster:

Email:

Phone:

Carrier/Administrator:

Applicant:

Date of Birth:

SSN#:

Employer:

WCAB#:

Claim#:

Date of Injury:

Entire Coverage or P.S.I. Period:

From: To:

Entire Employment Period:

From: To:

TD Paid $:

From: To:

Average Weekly Wages:

TD Rate: PD Rate:

Why TD Terminated?

PD Paid $:

From: To:

Total PD Advance:

Suggested Issues:
(please check all that apply)

Employment
Occupation
Injury
Insurance Coverage
Permanent Disability
Temporary Disability
Further Medical Care
Self-Procured Medical Care
Earnings
Dependency
Statute of Limitations
Apportionment
Jurisdiction
Vocational Rehabilitation
Subrogation
Other

Medical Preparation:

Original Medical Reports Are:
Attached
Filed

Copies served on Applicant:
Yes
No

Has further medical exam been scheduled?
Yes
No

If yes:
With Whom?

When?

Applicant's Medical/Legal Liens Paid:

(714) 935-0444
Godfrey Godfrey & Lamb, LLP
Attorneys at Law
2119 W. Orangewood Avenue
Orange, California 92868
(714) 935-9944 Fax
wpeterg@godfrey-law.com