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Litigation Referral
Please fill out the following online referral form. To download and save an editable copy of this referral form please select the PDF Referral Form link at the top right hand side of your screen:
Client Information
Adjuster:
Carrier/TPA/Self-Adm Employer:
Address:
City:
State:
Zip Code:
Phone:
Fax:
Email Address:
Employer Information
Employer:
Address:
City:
State:
Zip Code:
Phone:
Fax:
Title:
Employee Information
Employment
Insurance
Injury - AOE-COE
Injury - Nature/Extent
Earinigs
Occupation
Medical Tx
Temp Disibility
Perm Disibility
Appointment
15% Plus or Minus
Dependency
Statute of Limitations
VR/SJDB
Liens
Contribution/Other
Comment::
Critical Issues:
90 Day Decision Due:
Temporary Disability First Paid:
Temporary Disability Rate:
From:
To:
From:
To:
Permanent Advances $:
Input field
Benefit Printout provided
Total Medical Paid $:
Offer Alt/Mod/Reg Work:
Date:
From:
Hearing Scheduled for:
Comment
Scheduled Medical Exam
Depo of
File DOR
Prepare Appeal Due
Requested Attorney
Kevin L. Shaw
Richard M. Jacobsmeyer
Michael V.W. Crain
James H. Claffey
Sherry E. Nix
Brian A. Kreft
Office Location
Oakland CA
San Francisco CA
Los Angeles/Beverly Hills CA
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PDF Referral Form
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Litigation Referral
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Jake's eBlast
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PDRater
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Certified Specialist, Workers' Compensation Law The State Bar of California Board of Legal Specialization
Shaw, Jacobsmeyer, Crain, Claffey & Nix, LLP
475 14th Street Suite 230 Oakland, CA 94612 Phone:(510) 645-7172 Fax (866) 563-0092
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