Godfrey 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.

Or you can download, print, and fill out one of the following litigation referral sheets directly below and return to wpeterg@godfrey-law.com.


Printable Forms:


Begin Form*:

Today's Date:

Date of Hearing: (MO/DY/YEAR)

Adjuster:

Email:

Area Code and Phone:

Carrier/Administrator:

Applicant:

SS#:

Employer:

(1) EAMS/WCAB:

(2) EAMS/WCAB:

Claim #:

Date of Injury: (MO/DY/YEAR)



Entire Coverage or P.S.I. Period:
(Please format MO/DY/YEAR : "01/31/2014")

From:

To:

Entire Employment Period:
(Please format MO/DY/YEAR : "01/31/2014")

From:

To:

TD Paid $:

From:
(MO/DY/YEAR)

To:
(MO/DY/YEAR)

Average Weekly Wages:

TD Rate:

PD Rate:

Why TD Terminated?:

PD Paid $:

PD Paid from:
(MO/DY/YEAR)

PD Paid to:
(MO/DY/YEAR)
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


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:







Questions or Comments:

PRIVACY STATEMENT

Please be advised that information requested on this form will not be given or shared to a third party without the visitorís consent. This information will only be used to respond to the visitor in the event there are any questions or comments.

By submitting this form, I understand and accept the terms above.

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