Refer a Case

About the Referrer

Firm/company name

Name of referrer

Contact email address

Contact telephone

Office address

Suite/unit

City

State
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Zip/postal code

Case Overview

Claim number(s)

Additional details, observations

800 characters remaining

Claimant Info

First & middle names

Last ("family") name

Claimant address

Suite/unit

City

State
—Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingAmerican SamoaGuamNorthern Mariana IslandsPuerto RicoVirgin Islands

Zip/postal code

Country
—Please choose an option—AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChina, Hong Kong Special Administrative RegionChina, Macao Special Administrative RegionChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDemocratic People's Republic of KoreaDemocratic Republic of the CongoDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of KoreaRepublic of MoldovaRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (French Part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSarkSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaState of PalestineSudanSurinameSvalbard and Jan Mayen IslandsSwazilandSwedenSwitzerlandSyrian Arab RepublicTajikistanThailandThe former Yugoslav Republic of MacedoniaTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited Republic of TanzaniaUnited States Minor Outlying IslandsUnited States of AmericaUnited States Virgin IslandsUruguayUzbekistanVanuatuVenezuela (Bolivarian Republic of)Viet NamWallis and Futuna IslandsWestern SaharaYemenZambiaZimbabwe

Date of birth (yyyy-mm-dd)

Social security number (123-45-6789)

Claimant's Employer

Employer company name

Employer address

Suite/unit

City

State
—Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingAmerican SamoaGuamNorthern Mariana IslandsPuerto RicoVirgin Islands

Zip/postal code

Country
—Please choose an option—AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChina, Hong Kong Special Administrative RegionChina, Macao Special Administrative RegionChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDemocratic People's Republic of KoreaDemocratic Republic of the CongoDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of KoreaRepublic of MoldovaRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (French Part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSarkSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaState of PalestineSudanSurinameSvalbard and Jan Mayen IslandsSwazilandSwedenSwitzerlandSyrian Arab RepublicTajikistanThailandThe former Yugoslav Republic of MacedoniaTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited Republic of TanzaniaUnited States Minor Outlying IslandsUnited States of AmericaUnited States Virgin IslandsUruguayUzbekistanVanuatuVenezuela (Bolivarian Republic of)Viet NamWallis and Futuna IslandsWestern SaharaYemenZambiaZimbabwe

Insurance carrier

Case Details

Hiring date (yyyy-mm-dd)

Injury/incident date (yyyy-mm-dd)

Weekly wages (average)

TTD rate

TTD paid to date

"Paid-from" start date (yyyy-mm-dd)

"Paid-to" end date (yyyy-mm-dd)

Optional: additional start-and-end date range(s), one pair of dates per line

PD rate

PD paid to date

Total medical paid to date

Issues for litigation assignment (check all that apply)…
EmploymentCoverageInjury AOE/COEStatute of LimitationsOccupationAverage EarningsEntitlement to Temporary DisabilityEntitlement to Permanent DisabilityMedical TreatmentPanel QME Needed132a DefenseSerious and Willful Misconduct DefenseDependencySubrogationOther - specify below

If you checked "other," specify here…

Hearing scheduled?
yesnounknown

Wages statement, status
not applicableneed to requestrequestedreceivedunknown

Personnel file, status
not applicablerequestedreceivedneed to requestunknown

We have the authority to (check all that apply)…
Schedule depositionSubpoena recordsRequest Panel QMEArrange employer-level investigationArrange surveillance investigationOther - specify below

If you checked "other," specify here…

Claim form received by employer on… (yyyy-mm-dd)

Has this claim been denied?
yesnounknown

Does claimant have legal representation?
yesnounknown

Notice of representation received on… (yyyy-mm-dd)

Has the application already been filed?
yesnounknown

WCAB/ADJ Number

When did you receive the WCAB Notice of Application Filed? (yyyy-mm-dd)

Employer has an MPN?
yesnounknown

QME already selected?
yesnounknown

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.

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