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Woodall and Broome Case Assignment Form

- INVESTIGATIVE INFORMATION -
Client:  Requestor: 
Date:  Address: 

City:  State: 
Zip Code:  Client File Number: 
Phone:  Insured: 
Email: 

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: 
Zip Code:  Phone Number: 
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: 

Yes  

No

Children: 

Spouse’s Name:

Yes  

No

Please list children’s names and ages: 
Driver’s License Number:  Driver’s License State: 
Vehicle Description:  License Plate Nubmer: 
Occupation:   
 
Employer:  Address: 
Name of Contact Person:  Phone: 

May we call?

Yes

No

Nature of Injury:   
Limitations/Restrictions:   
Physican’s Name: 
Physican’s Address:  Rehab Supplier: 
Additional Information:   
Please upload all related attachments (as either images or PDFs) such as FROI, NOI, driver license and claimant pictures using the browse buttons below or email to swoodall@woodallandbroome.com

 

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