Referrer Name *

First Name

Last Name

Phone *

(###)

###

####

Referral Date

MM

DD

YYYY

Issues for Litigation Assignment *

Please check all that apply.

Employment

Coverage

Injury AOE/COE

Statue of Limitations

Occupation

Average Earnings

Entitlement to Temporary Disability

Entitlement to Permanent Disability

Medical Treatment

Panel QME Needed

132a Defense

Serious and Willful Misconduct Defense

Dependency

Subrogation

Other

Do we have authority to do the following?

Please select all that apply.

Schedule deposition

Subpoena records

Request Panel QME

Arrange employer level investigation

Arrange surveillance investigation

Other