GODFREY, GODFREY & ORTEGA, LLP - Litigation Referral

Litigation Referral

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:

LITIGATION REFERRAL SHEET*

* = required

Today's Date:	Oct,19,2021
From:	*
	Adjuster Carrier / Admin

Email:

Direct Line:

Applicant:	*	Employer:	*
DOB:	* (MO/DY/YEAR)	SS#:	*
WCAB #:	*	Claim #:	*

Date of Injury: (MO/DY/YEAR)	*

Entire Coverage or P.S.I. Period:
From: (MO/DY/YEAR)	To: (MO/DY/YEAR)
Entire Employment Period:
From: (MO/DY/YEAR)	To:(MO/DY/YEAR)

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)

Date of Hearing: (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
	Subrogation
	Dependency
	Statute of Limitations
	Apportionment
	Jurisdiction
	Vocational Rehabilitation
	Other

Medical Preparation:
(please check all that apply)

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:

* Note: One sheet each injury.

PRIVACY STATEMENT

Please be advised that information requested on this form will not be given or shared to a third party without the visitor�s 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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