Legal Referral Form

referral to:
Michael Sullivan & Associates
6151 W. Century Blvd., Suite 700
Los Angeles, California 90045
phone: (310) 337-4480
fax: (310) 337-4486

Claimant Information:
Name:
Phone:
Address 1:
Address 2:
City:
State:
Zip:
SS#: - -
Date of Injury: \n"; ?>
Date of Hire:
Date of Birth:
Last Day
Worked:
Average
Weekly Wage:		 $
Claim #:
Occupation:


Third Party Administrator / Insurance Carrier:
Name:
Address1:
Address2:
City:
State:
Zip:
Examiner:
Direct #:


Employer:
Name:
Phone:
Address1:
Address2:
City:
State:
Zip:
Self Insured? Yes No

If NOT,
Carrier:


Status
Has hearing been held or set? Yes No
Date:
Where?
Has medical been filed? Yes No
Served? Yes No
Is a Medical Exam Needed? Yes No
Has a Declaration of Readiness been received? Yes No
Application filed? Yes No
Subrogation? Yes No

If YES, against whom?
Medical Reports Enclosed:
Specifics Of Claim:
Instructions And Comments:


Benefits Paid Date Rate Amount
Temporary
Disability:		 $
Permanent
Disability:		 $
Medical: $
Rehabilitation: $
Life Pension: $
Death Benefit: $


Suggested Issues:
Injury Employment Occupation
Coverage Earnings Temp. Disability
Perm. Disability Past Medical Future Medical
Statue/Limitations Lien Claims Dependency
Costs Penalty Voc. Rehab


Claims Examiner:
Claims Supervisor:


 

© 2008 Michael Sullivan & Associates, P.C.