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Referrals

Our company Litigation Transmittal form is available below, or for download, for your convenience.

Litigation Transmittal Form

"*" indicates required fields

Client Information

Company*

Your Name*

Phone*

FAX

Email*

Assign To*

Please indicate specific attorney; if no specific attorney, please indicate "Fresno Office or "Bakersfield Office".

Case Information

Applicant/Plaintiff

Employer/Insured

Third-Party Administrator

Claim No.

WCAB No.

Date of Injury

MM slash DD slash YYYY

Hearing

DOR Filed

Yes

No

Hearing Set

Yes

No

Venue issue

Yes

No

Date of Hearing

MM slash DD slash YYYY

Medical

Medical Exam Set

Yes

No

Medical Exam Date

MM slash DD slash YYYY

Remarks

Remarks

CAPTCHA

Date

MM slash DD slash YYYY

Contact

Fresno
7112 North Fresno Street, Suite 300
Fresno, California 93720

Telephone: (559) 449-2558
Facsimile: (559) 449-2564

Bakersfield
1800 30th Street, Suite 340
Bakersfield, California 93301

Telephone: (661) 328-2200
Facsimile: (661) 328-0022

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