- Open New Case -


After filling out the Case Assignment Form, you may either PRINT the form for your records, and a copy to be sent to us via USMail, or you may click the SEND button and send us the information via the Internet.


Case Assignment Form

- INVESTIGATIVE INFORMATION -
Client:  Requestor: 
Date:  Address: 
     
City:  State: 
Zip Code:  Client File Number: 
Phone:  Insured: 
 

Budget:  Defense Attorney: 
Firm:  Phone: 

Case Type:   (Choose One)  
Workers' Compensation
Liability
Other  (Please Specify Below)
 
Date of Loss:  Receiving Benefits: 
      Yes    No
Address Benefits Being Sent To:  Doctor's Appointment: 
Working Light Duty:  When and Location?: 
Yes    No
Going To Rehab?:  When?: 
Yes    No
Is Claimant or Subject Represented by Council?:  Hearing Date: 
Yes    No      
- CLAIMANT/SUBJECT INFORMATION -
Claimant   Subject Address, City, State and Zip Code: 
Date of Birth:  mm/dd/yy Social Security Number: 
Race:   Gender: 
Male    Female
Hair Color:  Hair Style: 
Height:  Weight: 
Facial Hair:  Glasses: 
None    Beard    Mustache    Both Yes    No
Married:               Spouse's Name: Children: 
Yes   No   Yes   No
Please list children's names and ages: 
Driver's License Number:  Driver's License State: 
Vehicle Description:  License Plate Nubmer: 
Occupation:  Phone: 

Employer:  Address: 
Name of Contact Person:  Phone: 
Yes   No 
May we call?
YES   NO
 
Nature of Injury:   
 
Limitations/Restrictions:   
 
Physican's Name: 
Physican's Address:  Rehab Supplier: 
Additional Information:   
 


   


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