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 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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