Refer a Case

For general inquiries and messages, use our simple contact form.

Note: to expedite handling, please complete all relevant fields.

    About the Referrer

    Case Overview


    800 characters remaining

    Claimant Info

    Claimant's Employer

    Case Details

    Issues for litigation assignment (check all that apply)…

    Hearing scheduled?

    Wages statement, status

    Personnel file, status

    We have the authority to (check all that apply)…

    Has this claim been denied?

    Does claimant have legal representation?

    Has the application already been filed?

    Employer has an MPN?

    QME already selected?

    Case Files

    Optional: attach up to two relevant files.
    Accepted file types: .pdf, .doc, .docx, .xls, .xlsx, .jpg, .jpeg, .png.
    For other formats and alternate arrangements, please contact our office.


    I consent to this website storing my information in order to respond to my referral.